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Gambling Addiction: Etiology, Treatment and Prevention

6 CE Hours

By: Deborah Converse, MA, NBCT

Learning objectives

� Identify and explain five factors that determine classification of gambling addiction, according to the revised American Psychiatric Association DSM-5 criteria.

� Describe the prevalence of gambling addiction across age, gender, ethnic and socioeconomic status in the United States.

� List six signs and symptoms of a gambling addiction. � Explain two forms of treatment for gambling addiction.

� Describe and give examples of three types of disordered thought patterns that are found among addicted gamblers.

� Identify and discuss four risk factors that may lead to gambling addiction.

� Describe four negative consequences that affect the addicted gambler’s family and friends.

Introduction

An estimated $1 trillion is spent on gambling in the United States annually, according to one national study (Rose, 2010). Harmful effects of compulsive gambling on the individual include financial problems ranging from high debt, bankruptcy, poverty, legal problems, theft, prostitution, and attempting or completing suicide (National Council on Problem Gambling, 2011).

Gambling addiction can have a multitude of negative effects on the family. Statistics indicate that families of compulsive gamblers are more likely to experience domestic violence, higher divorce rates and child abuse. Children of problem gamblers are at a significantly higher risk of suffering from depression, behavior problems and substance abuse (Skolnik, 2011).

Gambling addiction is assuming alarming proportions, especially with the widespread popularity of online gambling. Problem gambling manifests itself in the form of various dysfunctional behaviors if not treated correctly.

Gambling is the nation’s foremost “silent addiction.” As one college counselor pointed out, “pathological gamblers don’t have track marks on their arms, their speech is not slurred and they are not staggering down the street. But on the inside, the emotional churn going on is equally as great as the substance abuser” (Henry, 2003).

Gambling addiction is a mental health problem that is one of many impulse-control problems. Types of gambling are as varied as the games available. Betting on sports, dog and horse races, lotto tickets, poker, slot machines, bingo, video lottery, power ball, blackjack or roulette are only a few of the activities in which compulsive gamblers engage.

The venue of choice for individuals with gambling addiction varies as well. While many prefer gambling in a casino, the rate of Internet gambling addiction continues to increase. Gambling addiction is also called compulsive gambling or pathological gambling.

Historical perspectives

America has always been a nation of gamblers, from the colonial era horse-race bettors of the 19th century and Mississippi riverboat card sharks to the millions who now annually gamble on the Las Vegas strip.

Since the 1970s, legalized gambling has taken hold of the country as never before. Gambling has rooted itself in scores of cities and small towns in every region of the country, resulting in direct fallout from gambling addiction (Skolnik, 2011).

Native American tribes have renegotiated compacts, and more than two dozen states allow casinos. State governments have joined, bringing private casinos, card rooms, video poker and slot machines by the tens of thousands into their jurisdictions.

The national poker craze has led to the game’s increased exposure on television. During one week in May 2010, 58 episodes of 14 different poker tournaments ran on eight different networks. This is in contrast to the mid-1990s, when a single network broadcast a one-hour-long poker show. (Rose 2010).

Internet gambling is still on the rise, although Congress has deemed it quasi-illegal. Forty-three states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands sponsor heavily promoted lotteries (Rose, 2010).

According to experts, gambling becomes a problem when it disrupts or damages personal lives or careers. Problem gamblers often devolve into pathological gamblers when gamblers lose control over their betting, when they gamble more often and for larger amounts and continue to gamble despite adverse consequences (APA, 2010).

Negative consequences resulting from gambling addiction not only affect family and friends, but also affect the workplace throughout a community. They run the gamut from increased absences, decreased work productivity, increased physical and mental health problems and a rise in divorce rates. Studies have also shown that pathological gambling has caused an increase in filings and claims for unemployment, welfare benefits and home foreclosures (Skolnik, 2011).

Further research conducted over the last couple of decades concludes that unremitting expansion of legalized gambling has helped turn great numbers of Americans into problem and pathological gamblers. A comprehensive analysis of 120 gambling prevalence research studies that looked at gambling behavior in the United States and Canada between 1974 and 1997 concluded there was a dramatic rise in the adult problem and pathological gambling rates. Over that time, the study showed a sharp increase in the percentage of lifetime problem or pathological gamblers to nearly 7 percent of the population (Shaffer et al., 1997).

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In 2007, Americans lost more than $92 billion on gambling, about nine times what they lost in 1982. That is almost 10 times what moviegoers in the United States spent on tickets during the same year (Rose, 2010).

Thirty-five years ago, casinos became legal in Nevada. As of 2010, a variety of gambling activities have been legalized everywhere in the United States except Utah and Hawaii. The majority of Americans now live within a three- to four-hour drive of a casino.

Because of this growth, millions of Americans have for the first time been directly exposed to gambling (Rose, 2010).

The result is a significant increase in the number of addicted gamblers around the country. There is a fairly obvious proposition at work: In communities where legalized gambling has been introduced, new problem and pathological gamblers have developed (Volberg, 2003). As gambling became more socially accepted and accessible during

the past two decades, adults in the general population have started to gamble in increased numbers, the Volberg study concluded.

Other prominent studies back up this notion. The gambling behavior survey carried out by the National Gambling Impact Study Commission determined those who live within 50 miles of a casino were more than twice as likely to develop significant problems as those who live between 50 and 250 miles from the establishment. Within the 50-mile zone, the pathological gambling rate was 2.1 percent; outside of that zone it was 0.9 percent (Welte, et al., 2003).

The conclusion was that proximity to gambling venues spurs higher problem gambling rates and has been supported repeatedly by other independent studies.

A review of the problem of pathological gambling in Nevada, which has the most extensive legal gambling market in the United States, will be reviewed in a later section.

Definition

Gambling addiction is gambling behavior that causes disruption in any major area of life, psychological, physical, social or vocational. The term gambling addiction includes the condition known as pathological or compulsive gambling (APA, 2010).

A progressive gambling addiction is characterized by: ● Increasing preoccupation with gambling. ● A need to bet more money frequently. ● Restlessness or irritability when attempting to stop. ● “Chasing” losses. ● Loss of control manifested by continuation of the gambling

behavior in spite of mounting serious, negative consequences.

There is a certain shame attached to confessing a gambling addiction in our culture, in some cases even more so than being an alcoholic or cocaine addict. Many still believe that people gamble excessively because of a lack of willpower or because they’re simply immoral. These antiquated beliefs are beginning to fade as doctors, scientists and researchers are increasingly concluding that pathological gambling is a behavioral addiction that affects the brain in much the same way as substance dependencies.

Research suggests that about one in two problem gamblers suffer other types of addictions (Goudriaan et al., 2006).

Beginning in 1980, modern psychiatry redefined gambling addiction. The publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) marked the first time pathological gambling was included (APA, 2010). This resulted in a major shift in how gambling addiction was seen by those in a wide range of fields, from doctors to judges, social workers and religious leaders. The condition began to be accepted by many as a medical disorder, as opposed to moral failing or sinful transgressions that stem from personal weakness. The DSM listing changed gambling addictions from vice to disease.

As the DSM-III and DSM-IV were released between 1987 and 2000, the definition of pathological gambling continued to evolve. It remained classified as an impulse control disorder, as such conditions of pyromania or kleptomania, rather than directly defined as an addiction (APA, 2010).

Under the most recent definition, pathological gambling is described as “persistent and recurrent maladaptive gambling behavior” indicated by

five or more of 10 symptoms. As the perception of problem gambling changed dramatically in 1980, so did the perception of the disorder.

In February 2010, a DSM-5 workgroup recommended that a new category of “behavioral addictions” be formed for the first time and suggested that pathological gambling be included as the sole disorder on the list. In psychiatry, only disorders involving substances such as alcohol and drugs have been considered full-fledged addictions. This proposed change would put gambling addiction on par with them. Final publication of the DSM-5 has been released as of May 2013.

The DMS-V workgroup has proposed that gambling addiction be reclassified from impulse control disorder not elsewhere classified to substance-related disorders, which will be renamed addiction and related disorders as described below:Gambling disorderA. Persistent and recurrent maladaptive gambling behavior as

indicated by five or more of the following:1. Is preoccupied with gambling, reliving past gambling

experiences, handicapping or planning the next venture, thinking of ways to get money to gamble.

2. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.

3. Has repeated unsuccessful efforts to control, cut back or stop gambling.

4. Is restless or irritable when attempting to cut down or stop gambling.

5. Gambles as a way of escaping from problems or relieving negative moods, such as feelings of helplessness, guilt, anxiety or depression.

6. After losing money gambling, returns for another day to get even (“chasing” one’s losses).

7. Lies to family members, therapists or others to hide the extent of involvement with gambling.

8. Has jeopardized or lost a significant relationship, job, educational or career opportunity because of gambling.

9. Relies on others to provide money to relieve a desperate financial situation caused by gambling

B. The gambling behavior is not better accounted for by a manic episode

Gambling severity

Dr. Iman Parhami, M.D. (2010), summarized an article submitted by Rosenthat et al. to the Journal of Addiction in March 2010. He noted that reduction of symptoms associated with gambling behavior and pathological gambling might not be meaningful because a single

act, event or slip-up could be catastrophic. Absence or reduction of gambling behavior may not mean improvement per se, but may be due to extrinsic factors, such as lack of funds, incarceration or social ultimatums.


A subjective method to assess severity may be based on recognizing the central component for addictive and self-distracted behaviors, which Parhami and Rosenthal believe to be the progressive loss of control. Progressive loss of control may be the most meaningful classification for severity and pathological gambling, but might be the most difficult to determine because it requires following the gambler for a period of time.

Clinicians have previously described this process as a three- to four-stage progression of losing control. These models have been modified into a new triangular model with four phases. A triangular model is used because gamblers can shift back and forth to any of the other three phases at any time, as described below (Rosenthal, et al, 2010):1. In the first phase, ego-systonic, many gamblers plateau and reduce

and control behavior or periodically get in trouble. There are big wins or fantasies of success with enhanced self-esteem. Gambling is not to solve problems in this phase. Some gamblers value the avoidance of feelings and the distracting aspect of gambling, and many emphasize how alive and special they feel.

2. In the second phase, referred to as out of control, they have a series of losses and discover that losing is intolerable to them. They abandon previous strategies and limits they made for themselves, and take increasingly greater risks in order to win back their losses all at once. There is an urgency to borrow money, lie to conceal what happened, and there is a clear loss of control. They hope to get even to cancel out their feeling of loss and guilt. It is as if they have never gambled, and the thought is “two wrongs can make a right.”

3. The third phase is ego-dystonic and begins when gamblers realize they will never get even. They stop caring and keep gambling even knowing they will lose. Their sloppy play, even when they have the right horse or the winning hand, serves to guarantee it. They insist that just playing is all that matters, and that it is no longer about winning. They want to feel action or excitement for its own sake. As this phase progresses, there is no longer any rationalization of why they gamble or attempt to undo problems. They just want to lose their money as quickly as possible, not because they are masochistic, but because it is only then that they will be able to stop and sleep. This phase is named the ego-dystonic phase, because the gambling seems to take on a life of its own, and the individual feels driven to do something that no longer makes sense or is in their control.

4. In the fourth phase, which is exhaustion, gambling behavior is halted due to added extrinsic/intrinsic factors such as exhaustion of funds, physical or psychological stress, social ultimatums or incarceration. In this phase, the gambler does not stop having urges or does not stop enjoying the gambling; rather he or she is not able to gamble. This may also explain why some researchers report gamblers stop due to “natural causes” without treatment. It also might explain why there are a high number of relapses after people seemed “cured” initially.

Time is not relevant for this process because gamblers can stay in phases from minutes to years. For example, with the enhancement in technology and accessibility gamblers can lose their entire savings and max out their credit cards in minutes with online gambling and electronic money transfers.

It is important for mental health providers to recognize this model and emphasize therapy as a way to prevent shifting to the severe phases.

Because the DSM-5 is a proposed revision and is still under consideration by the APA, it is important to consider information presented by other organizations dedicated to the prevention and treatment of gambling addiction.

The National Council of Problem Gambling is the national advocate for programs and services to assist problem gamblers and their families. It represents a cross-section of clinicians, researchers, problem gambling service administrators, the gambling industry and policymakers. Its mission is to increase the public awareness of pathological gambling, ensure the widespread availability of treatment

for problem gamblers and their families, and encourage research and programs for prevention and education (NCPG, 2010).

As an advocate for problem gamblers, the NCPG does not take a position for or against legalized gambling but concentrates on helping those with a gambling problem. Its 38-year history of independence and neutrality makes NCPG a credible voice on problem gambling issues (Whyte, 2010).

Keith S. Whyte, executive director of the National Council on Problem Gambling, submitted the following comments and information to the APA for consideration in April 2010. Here are some excerpts from a letter to Dr. David Kupfer, Chair, DSM-5 Task Force, as summarized below:

● Please accept these comments on the proposed changes to the classification of gambling problems in the DSM-5 on behalf of the Board of Directors of the National Council on Problem Gambling. The Board appreciates the significant work undertaken by American Psychiatric Association to improve the classifications of disorders, including gambling addiction, in DSM-5, and is pleased to provide additional information on four specific issues:1. The importance of the criterion “has committed illegal acts” in

the diagnosis of pathological gambling.2. The impact of changing the diagnosis threshold.3. The need to recognize a broader spectrum of gambling

problems by adding a subclinical category of “problem gambling” analogous to alcohol and substance abuse or developing severity criteria.

4. The need to make provisions for sub-typing of problem and pathological gamblers to recognize different pathways into the disorder.

● Illegal acts.The NCPG Board questions elimination of the diagnostic criterion “has committed illegal acts such as forgery, fraud, theft or embezzlement to finance gambling.” The DSM-5 website references only one source for this proposed change (Strong & Kahler, 2007). In population surveys, researchers have found that while “illegal acts” is the DSM-4 criteria least likely to be endorsed, this item is the most reliable discriminator between individuals who score at the highest level of pathological gambling severity (endorsing 8 to 10 criteria) and those who endorse fewer criteria.

● Changed diagnostic threshold.Under DS-5, a diagnosis of pathological gambling requires endorsement of five out of 10 criteria (50 percent). Under the new proposal, diagnosis would require endorsement of five out of nine criteria (55.5 percent). In addition, the DSM-5 website lists several published references that support lowering the threshold to 4 out of 10 criteria. There are no references provided in support of increasing the threshold.

● Subclinical/severity classification. ○ In addition to the need to lower the threshold for a pathological

gambling diagnosis, the NCPG believes there is a need for a subclinical category of “problem gambling” that more accurately reflects the full spectrum of gambling involvement in the population.

○ Internationally, there is a large body of research supporting the view that gambling occurs on a continuum that ranges from no gambling to social gambling to problem gambling to pathological gambling (Gambino, 2009; Korn, Gibbons, & Azmier, 2003); (Ministry of Health, 2008). We believe that it is essential that the different levels of severity of gambling involvement be reflected in the DSM-5 classifications. We recommend severity specifiers be developed for moderate and severe gambling disorders, mirroring the proposed substance-use disorder criteria.

● Sub-typing. ○ Finally, while it might not be relevant to the diagnostic

criteria, the NCPG Board believes that the evidence DSM-5 information on gambling disorders should reflect sub-types


of problem and pathological gamblers There is a substantial and growing evidence that disordered gamblers are not a homogeneous group but instead are heterogeneous.

○ “There are clearly diverse pathways into problem and pathological gambling as well as the range of motivations for gambling involvement such as the need for action or escape. Sub-typing of problem and pathological gamblers would be particularly helpful in making decisions on medication usage where gambling driven by urges, related to difficulties inhibiting behavior, may respond differently to different pharmacotherapy.”

○ “If the criteria remain as proposed, the NCPG Board questions the necessity of changing the label from “pathological

gambling” to “disordered gambling.” However, if proposed severity criteria are adopted or an abuse/dependence distinction is made, the Board supports the label of “gambling disorder” or “gambling abuse and gambling dependence.

Thank you for the opportunity to share our views. We would be happy to amplify any of these comments and answer any questions you might have (Whyte, 2010).”

As noted above, in the current DSM, pathological gambling is defined as a “persistent and reoccurring” behavior, and repeated studies have shown that gambling addiction is difficult to treat, reflected by the fact that relapse rates for such gamblers are high.

Signs and symptoms

Gamblers can have a problem without being totally out of control. Unpleasant feelings — such as stress, depression, loneliness, fear and anxiety — can trigger compulsive gambling or make it worse. After a stressful day at work or after an argument with a spouse or coworker, an evening at the track or the casino can seem like a fun, exciting way to unwind.

Here are some myths and facts about gambling addiction and problem gambling often held by gamblers and their family and friends (Department of Mental Health & Addiction Services, 2011):

Myth: Someone has to gamble every day to be a problem gambler.Fact: A problem gambler may gamble frequently or infrequently. Gambling becomes a concern if it causes problems in other areas of the person’s life.

Myth: Problem gambling is not really a problem if the gambler can afford it.Fact: Problems caused by excessive gambling are not just financial. Too much time spent on gambling can lead to relationship breakdown, loss of friendships and problems at work.

Myth: Partners of problem gamblers often drive the person to addiction.Fact: Problem gamblers often rationalize their behavior. Blaming others is one way to avoid taking responsibility for their actions, included treatment needed to overcome the problem.

Myth: If a problem gambler builds up debt, family and friends should help take care of it.Fact: Quick-fix solutions may appear to be the right thing to do. However, bailing the gambler out of debt may actually make matters worse by enabling problem-gambling behaviors to continue.

Families and friends might recognize the following signs as indicators of a gambling problem (MHAS, 2011):

● The individual becomes increasingly defensive about his or her gambling. The more a problem gambler is in debt, the more the need to defend gambling as a way to get money. The person may become secretive, defensive or even blame other family members for the need to gamble, telling them that it is for the family and that they need to trust that the “big win” will happen.

● The individual suddenly become secretive over money and finances. He or she might show a new desire to control household finances, or there might be an increasing lack of money despite the same income and expenses. Savings and assets might mysteriously dwindle, or there may be unexplained loans or cash advances.

● The individual may become increasingly desperate for money to fund the gambling. Credit card bills may increase, or the gambler may ask friends and family for money. Jewelry or other items easily pawned for money may mysteriously disappear.

The following list contains some common signs and symptoms of pathological gambling. The following symptoms are not the result of other mental health problems in the cases of pathological gambling (MHAS, 2011 and Jordan, 2009). The person:

● Gains a thrill from taking big gambling risks. Takes increasingly bigger gambling risks.

● Is preoccupied with gambling. ● Relives past gambling experiences. ● Gambling as a way to escape problems or feelings of helplessness,

guilt or depression. ● Takes time from work or family life to gamble. ● Conceals gambling. ● Feels guilty or remorseful after gambling. ● Steals to gamble. ● Has failed efforts to cut back on gambling. ● Lies to hide gambling. ● Needs more and more money for gambling to achieve the desired

level of gambling enjoyment. ● Returns to gambling after losing money in an effort to recoup losses. ● Commits crimes such as embezzlement, fraud or forgery to finance

gambling. ● Depends on others for money to resolve dire financial situations

that result from gambling. ● Risks important relationships, employment or other opportunities

because of gambling.

Compulsive gambling typically begins in the late teen years, and on rare occasions, gambling becomes a problem with the very first wager. More often, a gambling problem progresses over time, and many people spend years enjoying social gambling without any problems.

More frequent gambling or life stresses can turn casual gambling into something much more serious. During periods of stress or depression, the urge to gamble may be especially overpowering. Eventually, a person with a gambling problem becomes completely preoccupied with gambling and getting more money to gamble (Mayo, 2011).

For most compulsive gamblers, betting is as much about money as it is about excitement. Sustaining the thrill gambling provides involves taking increasingly bigger risks and placing larger bets, which may involve money the gambler cannot afford to lose. Unlike most casual gamblers, compulsive gamblers are compelled to keep playing to recoup their money, a pattern that becomes increasingly destructive over time.

Compulsive gambling can have profound and lasting consequences including:

● Failed relationships, loss of family and friends. ● Financial problems, including bankruptcy. ● Legal problems or incarceration. ● Job loss or professional stigma. ● Development of associated problems, such as alcohol or drug abuse. ● Suicide.


Gambling terms

The UCLA Gambling Studies Program (2010) identified a list of gambling terms as follows:

● Action – Amount of money gambled. ● Banker – The dealer that the players gambler against. ● Bankroll, access – Total amount of money the player has available

to gamble. ● Chase – When the gambler increases his wagers to recover losses. ● Comps – Gifts given by casinos to attract gamblers.

● Juice, rake – Commission given to the house or sports book after a wager or hand is played.

● Parlay, teaser – A wager involving more than one selection; player is given increased odds because all teams selected must win.

● Straight up – A wager on a sports game without a spread. ● Rack – A plastic container to transport or count large

denominational coins, slot machine tokens and casino plastic chips ● Tilt – After losing a wager or hand, the player has a wild,

uncontrollable reaction.

Prevalence

● According to recent research, about 2.5 million adults in America are pathological gamblers, and another 3 million of them are considered problem gamblers.

● Fifteen million adults are at risk of problem gambling, and about 148 million are low-risk gamblers.

● Gambling addiction statistics show that more than 80 percent of American adults report having gambled at some point in their lives.

● Gambling addiction statistics reveal that more than $500 billion is spent annually on wagers.

● The statistics show that during any year, 2.9 percent of U.S. gamblers are considered to either be pathological or problem gamblers.

● Gambling addiction statistics of co-occurrence of gambling and alcohol dependence revealed problem drinkers are more likely to have a gambling addiction.

● 60.1 percent of pathological gamblers were also addicted to smoking cigarettes. (Skolnik, 2011), (Shaffer, 2010) and (Rosenthal, 2010).

Mood and anxiety disorders

● 37.9 percent of pathological gamblers were also diagnosed with mood disorders.

● 37.4 percent of pathological gamblers were diagnosed with anxiety disorders (Rosenthal et, al. 2010).

Gender

● Although more men than women suffer from pathological gambling, women are developing this disorder at a higher rate, now making up as much as 25 percent of pathological gamblers.

● Women’s symptoms of gambling addiction tend to worsen faster once compulsive gambling develops.

● Men tend to develop this disorder during their early teenage years, while women tend to develop it later.

● Gender-based differences in gambling addiction include the tendency for men to become addicted to more interpersonal forms of gaming, like blackjack, craps or poker, whereas women tend to gamble on slot machines or bingo.

● Men with pathological gambling tend to receive counseling about issues other than gambling less often than their female counterparts. (Shaffer, 2010)

Ethnicity

Gambling addiction is seen more among Caucasian Americans than African-Americans and Hispanic Americans (UCLA, 2010).

In 2000, the U.S. Census Bureau defined Hispanic ethnicity as being of Mexican, Mexican-American, Chicano, Puerto Rican, Cuban or other Spanish/Hispanic origin or heritage. Census data for the year 2000 indicated that more than 35 million residents in United States were Hispanic, which constituted 12.5 percent of the total U.S. population (UCLA, 2010).

● Data indicates that nearly 83 percent of individuals of Hispanic heritage have gambled in the past year.

● Little research has been published on gambling problems among Hispanics, in fact, only two prevalence studies using national samples have examined the rates of gambling problems among Hispanics.

● Both studies suggest that when the prevalence of pathological and problem gambling is combined, the prevalence of gambling problems among Hispanics is similar to other groups.

● Examining the prevalence of pathological gambling among Hispanics suggests that pathological gambling may be more common among Hispanics relative to national prevalence rates.

Very little research has examined gambling behavior among significant variables related to gender, acculturation, country of origin and immigration history among Hispanics. Further research and understanding of gambling problems among Hispanics could help target prevention

efforts, identify risk and protective factors relating to gambling problems, and help design culturally tailored treatment modalities.

Asian Americans, especially those of Chinese, Vietnamese and Korean origin, gamble at a higher rate than Americans from other ethnic backgrounds and suffer as problem gamblers at a higher rate (Skolnik, 2011).

One possible explanation is that there are no religious prohibitions that warn against gambling in Asian cultures as there are in several Christian denominations, Islam and other faiths. In fact, gambling and religion in China are often part of the same general belief system.

In some Asian communities, gambling is considered a rite of passage, an activity tacitly or explicitly encouraged.

Numerology is important in many Asian cultures. Many Chinese, for example consider the numbers 6 and 8 lucky. Conversely, the number 4, which when spoken in Cantonese and Mandarin sounds like the word for death, is considered unlucky. As the novelist Amy Tan wrote in her book, “Saving Fish from Drowning,” the “Chinese kind of Buddhism” entails strong desires for riches, fame, and a large number of sons, as well as good luck at gambling” (Skolnik, 2010).

If these beliefs fade when Asian immigrants or refugees make their way to the United States, they do so slowly. Indeed, the gambling bug appears almost as strong in second and third generation Asian Americans as it does in those who made the trip to America.


Gambling is inextricable part of the mix of life in San Francisco’s Chinatown, the largest and oldest Chinese settlement in the Western United States. According to Kent Woo, executive director of the Chinese Health Coalition in San Francisco, there are more state lottery outlets in Chinatown per capita than elsewhere in the state. “They’re sold in bakeries, dime stores, groceries. They’re everywhere,” he said (Woo, 2011).

Gambling operators, especially in the casino business, have for decades been aware of the value of building a strong base of Asian gamblers. In recent years, their efforts have influenced the way casinos are designed and which games are offered. Casinos send fleets of buses to any nearby Chinatown to shuttle Asian gamblers to the casino. They created special Asian-themed high-roller clubs with private gambling and dining rooms, and some Las Vegas mega-casinos avoid calling the 4th and 40th hotel floors by those numbers because of the negative connotations of the number four in Chinese (Rivlin, 2007).

The phenomenon of Asian gambling addiction has come to the awareness of social workers, researchers and community activists around the country with increasing emphasis in recent years. Asian health groups for the first time are training counselors to deal with the problem. Activists infuriated at what they call the “predatory efforts”

of gambling businesses to entice Asians to their establishments and equally aggravated with politicians for legalizing gambling in their communities in the first place are starting to fight back (Woo, 2011).

Native American teens and adults were found to have higher percentage of gambling addiction at 15.69 percent of the population compared to 2.2 percent of the Caucasian population studied. Native American males and females are at equal risk of developing a gambling addiction. Among American Indians treated for alcohol dependency, 22 percent also experienced gambling addiction, compared to 7.3 percent of Caucasian patients treated for alcohol and gambling addiction (UCLA, 2010).

Since 1988 with the passage of the Indian Gaming Regulatory Act (IGRA), Native American Indian tribes rapidly opened up casinos, and Indian participation in recreational gambling increased. This led to increasing problem and pathological gambling among Native Americans. Researchers identified factors related to the increased predisposition of Native Americans to develop pathological gambling. These included economic status, unemployment, increased alcohol use, depression, history of trauma and lack of social alternatives (UCLA, 2010).

Age

The young are especially at risk for developing gambling problems.

Compared to drugs and alcohol, which have been around colleges for decades, the addiction of gambling is a relatively new addiction on campuses. It is one of the most widespread and serious concerns affecting students today. A gambling network in a school can be disguised as a group of students getting together. In this Internet age, bets can be made online or via cell phones. This addiction can involve an entire school and be undetected. Because the rewards are something that resonates with almost everyone, it seems very harmless and is very tempting to make quick money.

According to the Annenberg Public Policy Center’s 2005 National Center of Youth:

● There are 2.9 million Americans ages 14 to 22 who gamble on cards once a week.

● About 50.4 percent of male college students gamble on cards once a month.

● 26.6 percent of female college students gamble on cards at least once a month.

○ This is half of the entire male student body and a quarter of the female student body.

● Gambling is particularly tempting to college students because risk-taking behaviors are common.

● The legal age for gambling is 18 years old in many states, making it a socially permissible behavior.

● The forms of gambling among students vary greatly depending on the individual states being surveyed.

Among the common gambling activities for college students are (Jordan, 2009):

● Casino activities. ● Cards at casinos. ● Gambling machines. ● Playing the lotto. ● Formal card games with friends for money. ● Internet gambling ● Poker tournaments.

The Internet has provided unprecedented access to online gambling. Currently there are more than 2,000 gambling websites that take in over $4 billion annually (Aire, 2003)

Here is an example of on-line gambling as described by one college-aged compulsive gambler:

“It’s 2 a.m. I’ve got an economics exam very early in the morning. I can stay on for just one more tournament. This time I can win, I can feel it. I need to make up for what I lost today. I absolutely have to. Maybe I can buy a new outfit for this weekend or put a little bit of money toward my credit card bill. I can feel it. This is the one. Come on. Aces, aces… I am an addict. I’m not alone. This is a new addiction, and my 2 a.m. pre-econ exam, late-night binging is what I call the “gambling me.” The reason I didn’t connect this directly to myself is because I never knew I was capable of an addiction. I’ve never smoked or used drugs and only drink socially. I was the last person in the entire world that I thought could be addicted to anything.”

- Lauren Patrizi, Loyola University, 2005, at a Gambler’s Anonymous meeting. (Jordan, 2009)

Problem gambling involves more than one symptom but less than five symptoms required to qualify for the diagnosis of compulsive or pathological gambling. Binge gambling is a subtype of compulsive gambling that involves problem gambling but only during discrete periods of time. That is different from a gambling addiction, which tends to involve excessive gambling behavior on an ongoing basis and includes persistent thoughts or obsessing about gambling, even during times when the person is not engaged in gambling (UCLA, 2010).

Sports wagering, beginning in high school and increasing in college, is done by 50 percent of student athletes (Engwall, Hunter, and Steinberg, 2003). Lesieur (1991) reported 85 percent of college athletes had participated in betting, and 23 percent surveyed showed evidence of pathological gaming behavior.

Physically and psychologically tied to a campus, college students are more interested in the outcomes of sporting events, and when combined with easy access to alcohol and high-speed Internet, many post-secondary institutions find their students engaging in gambling at much higher rates than the general population (Henry, 2003).

The University of Kansas director of counseling services noted gambling allows students to feel intimately involved in the game (Aire, 2000). The gambling recovery counselor stated, “The more someone knows about a given sport, the more they believe their decision-making gives them a significant advantage.” This develops a level of “emotional invincibility in the addiction” (Henry, 2003). With easy access to gambling and a need to feel part of the larger organization,


pathological gambling associated with betting on sporting events has risen significantly in the past 10 years. (Jordan, 2009).

In one extreme case, a student at the University of Wisconsin murdered three roommates because he owed them thousands in gambling debts. The trio had helped him place bets with an offshore gambling company. He had lost $15,000 gambling and withdrawn $72,000 from his bank account to support his habit before he committed the murders (Wexler and Isenberg, 2002).

Robert L. Custer, M.D. discusses the four phases of gambling and developed an Adolescent Chart of Compulsive Gambling, which can apply to adults as well:

● The first phase: Winning The start of the compulsive gambling is that of immediate gratification when a gambler likely wins more than he loses. The wins reinforce his love of the sport. During the winning phase, a gambler may develop the illusion that he or she is “skilled” at the game. This phase is usually the first three years of gambling. This phase is characterized by:

○ Occasional gambling and fun. ○ Excitement before and during gambling. ○ Increasing the amount of money that is wagered. ○ Frequently winning. ○ More frequent gambling. ○ Fantasizing about winning. ○ Lying to parents about gambling. ○ Fantasy thinking.

● The second phase: LosingThe gambler’s luck does not run forever, and after a while, he starts losing more money. Paradoxically, a losing phase does not discourage the gambler. During the losing phase, the gambler feels tempted to gamble more and with larger amounts of money. He is convinced that he is simply on a losing streak and merely needs one win to get back his momentum. He invests on the “long shots” that, while having low odds of winning, will pay big, according to his thought process.

He may engage in a behavior called “chasing losses.” This means increasing gambling with larger bets in hopes of winning back the losses. In the phase of chasing losses, the lies begin, and the gambler lies to maintain the façade that he is winning. He maintains that he is still financially viable and competent at the game.

He continues to boast about his gambling skills, talks about his winning but rarely about his losses. When he suffers his first major setback, which places him in deep financial trouble, he makes up a lie to get a loan. He considers a bailout as a win and is back in action and gambling even more feverishly then before. In this phase, he seems to lose almost all the time, and his life has become unmanageable. It is impossible to persuade others to provide a loan, and relationships with his family and friends are rapidly deteriorating. This phase is characterized when the gambler:

○ Is obsessed with gambling and cannot stop. ○ Has debts that pile up. ○ Is careless about family and friends. ○ Brags about wins. ○ Blames losses on bad luck.

○ Covers up gambling. ○ Loses time from school or work. ○ Is irritable, restless, depressed. ○ Drops extracurricular activities (social activities for adults). ○ Experiences a drop in grades drop (or work performance drops). ○ Increases the money and time spent gambling.

● The third phase: DesperationThis is the point when the gambler becomes obsessed with gambling and feels compelled to carry it through. Even though he knows he will lose, he still gambles. His life becomes completely out of control, and when others don’t believe his lies, he becomes angry, blaming them for his problems. He must obtain money to gamble at all costs, and illegal activity may occur through embezzling or stealing money. He will consider these as loans, which will be paid back from the big win he believes he will have.

The gambler often has an outward appearance of being in total control. He is still convinced that everyone believes his lies and becomes angry when they don’t. Outwardly, he blames everyone but himself for the unfortunate circumstances now occurring. Inwardly, the gambler is in severe anguish, truly loves his family and wants things to be like they used to be. He wants to correct the instability but is compelled to gamble though he does not know why. This phase is characterized when the gambler:

○ Sells personal belongings. ○ Is unable to pay debts. ○ Drops out of school (or work for the adult). ○ Sells family valuables. ○ Has thoughts of crime. ○ Feels out of control. ○ Feels remorse, shame or panic. ○ Withdraws from family or friends. ○ Blames others. ○ Feels guilty. ○ Is involved in legal action.

● The fourth phase: HopelessnessUntil recently, only three phases of pathological gambling have been noted. Many clinicians and experts who treat pathological gambling now say a fourth phase exists for both action-seeking and escape gamblers (Parhami, 2010).

Once the gambler has been through the desperation phase, it would seem that everything bad had occurred. However in the hopeless phase, pathological gamblers have “given up.” They believe nothing can help; they don’t care if they live or die, in fact many believe suicide is the only way out and they consider that during this phase. Most will commit actions that could place them in jail or prison. Clinical depression is a given and they believe no one cares and no hope is available. The hopeless phase is the time when the pathological gambler either gets help or attempts suicide or suffers extreme depression. This phase is characterized by the gambler’s:

○ Despair. ○ Thoughts or attempts of suicide. ○ Arrest. ○ Use of drugs and alcohol. ○ Emotional or physical breakdown.

Elderly

Sam Skolnik (2010) reports the following statistic on elderly gamblers: ● Individuals over 65 are the fastest-growing group to become

addicted to gambling. ● With the elderly population growing, 80 percent of the over-65

population had gambled in 1998. ● 65 percent of all revenues in Atlantic City casinos come from

elderly gamblers.

● Studies found that elderly women gambled 249 percent of their monthly income. Many stopped taking meds, skipped meals, stole money from others, gambled with credit cards, and gambled away their mortgage, retirement, insurance, savings and homes. They are a particularly vulnerable group because they’re living on fixed incomes with few ways to recoup the money they have lost.

● Many casinos aggressively market to the 50-plus crowd, providing cheap buffets, coupons, drug discounts sometimes up to 50


percent, and bus the elderly from nursing homes and retirement centers.

● The elderly are often victims of lottery scams and other individuals who prey upon their vulnerability.

● Many elderly individuals have to turn to their families for assistance, but many are too ashamed to seek help, and the rate of suicide among elderly gambling addicts is alarmingly high, nearly three times the national average.

Military personnel

● The Pentagon operates several thousand slot machines on U.S. military bases abroad. These machines raise revenues of $130 million per year, which goes toward recreation programs for the troops, including movie theaters, concerts and swimming pools.

● According to a 2007 CNN story, there are 3,000 slot machines posted at Army and Marine bases.

● The number of machines at Air Force and Navy facilities wasn’t immediately disclosed.

● The Pentagon confirmed it has 8,000 slot machines on 94 overseas bases.

● The Army also runs bingo games on U.S. bases, which are comparatively modest, profiting the military at least $7 million annually.

● Young soldiers, often competitive, risk-takers by nature, are at a high risk for developing gambling problems. John Kindt (2007)

of the University of Illinois studied the issue and found that about 2.2 percent of military personnel indicated they are pathological gamblers, significantly higher than the percentage of adult civilian Americans (Skolnik, 2011).

● A statement by an undersecretary of defense said the slot machines provided “controlled alternatives to unmonitored off-base gambling venues and offers a high payment percentage, making it more entertainment oriented than found in typical casinos” (CNN, 2007).

The CNN story centered around Aaron Walsh, a decorated Apache helicopter pilot with the Army who became addicted to slot machines he found in bases in Germany and South Korea. He received treatment through the military’s only gambling treatment facility at Camp Pendleton in California, but it didn’t help. He was kicked out of the military in 2005. A year later, after a visit to a casino in Bangor, Maine, he killed himself. (CNN, 2007).

Etiology

As with other mental health issues, compulsive gambling may result from a combination of biological, genetic, social and environmental factors. Gambling addiction, like other emotional conditions, may be the result of a combination of biological factors, thought patterns and social stressors.

Compulsive gambling affects both men and women and cuts across cultural and socioeconomic lines. Although most people who play cards or wager never develop a gambling problem, certain factors are often associated with compulsive gamblers and elements that increase the likelihood that the individual will develop a gambling addiction.

Risk factors for developing pathological gambling include schizophrenia, mood problems, antisocial behavior, personality disorder, bipolar disorder, and alcohol or cocaine addiction as described below:(Mayo, 2011)

● Behavior or mood disorders. People who gamble compulsively often have mood disorders such as anxiety and depression, as well as attention-deficit/hyperactivity disorders.

● Family influences. If a parent had a gambling problem, chances are greater that children in the family will develop gambling problems.

● Personality characteristics. Individuals who are highly competitive, restless, or easily bored have an increased risk to develop a gambling problem.

● A diagnosis of bipolar disorder. Exorbitant spending in the form of compulsive gambling may be a symptom.

● Parkinson’s disease or restless leg syndrome. Medications used to treat these disorders have been observed to develop compulsive gambling in some individuals.

● Alcohol and cocaine addiction are risk factors for pathological gambling.

● Biochemical factors. In some individuals, compulsive behaviors can be connected to increased activity of the chemical messenger dopamine in the brain or low serotonin levels.

○ For the last decade, researchers have studied how biochemical substances such as dopamine work in the gamblers’ brain.

Dopamine is the neurotransmitter that helps assess awards such as food. When the body experiences pleasurable things, anything from a tall glass of lemonade to a slot machine win, dopamine neurons fire. They help the brain learn about pleasure, including predicting when the sensation my return (Goudriaan et al).

○ Addicted gamblers are different from non-addicted ones in the ways their dopamine systems function. Some researchers believe that during the first gambling experience of some pathological gamblers, a huge dopamine rush can occur that gets planted in their memory. When that happens, the addicted gamblers, like cocaine addicts, develop reward systems that respond to pleasing stimuli differently than non-addicts. An increasingly high level of reward has to be given for many addicted gamblers to continue to feel pleasure (APA, 2010).

Studies have noted that the rush that gamblers crave is the high they feel when they make a bet, and sometimes when just anticipating the bet. Blood surges to the face and the mouth dries up. Concentration narrows, as time seems to slow. The high is fleeting, but is repeated as soon as the gambler makes the next bet. The feeling exists whether the bet is won or lost, but can spike, especially if it’s more than expected. The experience has been compared to snorting a line of cocaine (Skolnik), 2011).

Using an MRI scanner, neurologists in Hamburg, Germany, gauged the responses of 12 gambling addicts and 12 non-addicts to a card guessing game. When participants picked the correct card, they won a euro. The non-addicts picked the right card, which increased their blood flow to the ventral striatum, a portion of the brain with dopamine receptors that measures rewards. Comparably, the addicted gamblers’ brains had far less blood flow to the area, indicating they needed a price much larger than a single euro to become excited (Lewis, 2006).

People who suffer from compulsive gambling have a tendency to be novelty seekers. Individuals who have a low level of serotonin in the brain are at higher risk for developing pathological gambling.

Which came first, the gambler or the casino?

The casino industry created the National Center for Responsible Gaming (NCRG) to try to establish the idea that pathological gambling is caused by gamblers who suffer from “addictive personalities.” Under this theory, casinos and other gambling operators are not

responsible in any way for getting gamblers hooked. This not only aided the industry and its state-by-state legalization fights, but it also established a ready-made defense against potential lawsuits. Many NCRG-issued grants study genetic, neurological and chemical causes


of gambling addiction. Specifically, several research efforts have delved into how gambling affects the brain, including surveys into brain imaging and possible drug treatments (Skolnik, 2011).

Other research has found links between gambling addiction and other addictions or impulse-control behaviors. Pathological gambling is often just one manifestation of addiction disease with “multiple opportunistic expressions.” Shaffer (2010) calls this the “syndrome model” of pathological gambling. This idea supports the notion that problem gamblers have addictive natures through which they’re also psychologically predisposed to abuse alcohol, drugs or sex.

A logical extension of this argument is that if the typical problem gambler couldn’t express his or her addictive personality through buying lottery tickets or playing the slot machines, they would simply shop to excess, take addictive drugs or find other ways to express their illness. Therefore, casinos cannot be blamed for being around to nourish their addictions (Skolnik, 2011).

One way to cast doubt on gambling industry-funded research is to look at what’s being studied, and how industry-funded researchers are trying to define the issue. Another way is to look at what they’re not studying (Shaffer, 2010).

The gambling industry has not touched on many issues necessary to develop a well-rounded view of gambling addiction, its causes or its consequences.

The following topics have never been funded for study by the NCRG: ● The manipulation of slot and video poker machines, including

video lottery machines, to make them especially addictive. ● Treatment for gamblers addicted to these machines, which is more

difficult than treating other forms of gambling. ● Casino player reward programs, also known as player loyalty

programs, and their role in addiction and relapse. ● Underestimation of gambling-added tax generated from casinos

and other gambling businesses, which provide the majority of the revenue.

● No studies focused on the social cost of legalized gambling, including suicide.

● No detailed studies have been conducted on the connection between problem gambling and other social costs, such as bankruptcies, divorces or gambling-related crime.

Critics say there is little mystery about why the NCRG has not studied the topics listed above. Such studies have the potential to view casinos as businesses increasingly designed to draw as much money as they can from addicted gamblers, despite the negative consequences that spread from the addicts to their families, friends, colleagues and communities. “They are not going to find anything that’s going to hurt them, or has the potential to hurt them,” said Joanna Franklin, a member of several committees of the National Council on Problem Gambling (NCPG, 2010).

“It is increasingly important that research continues into all types of new problem gambling treatment because it’s clear that the gambling industry remains busy finding novel ways to entice gamblers to spend more money than they intend” (Ferrell & Gold, 1998).

Slot machines play a big role. More than a decade ago, casino moguls began recognizing that electronic gaming devices, from traditional slots to video poker, video keno and bingo, were their biggest profit-drivers. They did this by granting slots an increasingly greater amount of space on casino floors. According to a “60 Minutes” report that aired in January 2011, the number of slots had risen to almost 850,000. (Skolnik, 2011).

Slots of different varieties are currently legal in 37 states, according to the American Gaming Association. On average, these machines take in more than $1 billion in wagers, some of which is paid back to the gamblers. The rest, called the “hold,” is what casinos make. In 2003,

North American casinos won $82 million dollars from slot machine players per day (Cooper, 2005).

Given that they can be so easily designed to manipulate gamblers’ emotions and drives, their potential seems almost limitless. Officials with International Game Technology, the country’s largest slot machine maker, made it clear that their goal is to stimulate gamblers into playing for longer periods of time. Their primary aim: “Make people want to sit there, use sight, sound, and everything in our disposal to get people’s juices going” (Rivil, 2004).

The cumulative effect is a stronger addictive pull, experts say. “No other form of gambling manipulates the human mind as beautifully as these machines. I think that’s why that’s the most popular form of gambling with which people get into trouble,” said veteran gambling addiction researcher Nancy Petry of the University of Connecticut School of Medicine (Rivil, 2004).

Gary Loveman, CEO of Harrah’s Entertainment since 2003, called the mega-casinos on the Las Vegas strip “slot boxes”; however, slot design is just part of the picture. Customers need to get to the gambling hall in the first place to play the machines. Sometimes that means they need to be coaxed back in (Greenfield, 2010).

Casino marketers have been refining their player reward programs to do that, and the program at Harrah’s sets the standard. The casino giant’s total reward player loyalty program has a customer database of more than 40 million players (Greenfield, 2010). To analyze the data, Harrah’s spends $100 million per year on information technology and related costs. Computer profiles are built on players that include types of games they like, how much they bet, how long they play in a given session, where they like to eat, shop and more. Customers of each of Harrah’s 52 casinos are then sent targeted enticements by e-mail and regular mail to come back and play more. The program has driven gambling revenues to 80 percent of Harrah’s $9 billion business (Greenfield, 2010). The industry standard is 45 percent.

Loveman and his number crunchers learned that elderly slot players lost more money to Harrah’s than any other demographic. They also discovered that 90 percent of Harrah’s profits came from roughly 10 percent of its most devoted gamblers (Binkley, 2008). Harrah’s data suggest that addicted gamblers are providing a disproportionate share of all casino profits.

This raises an uncomfortable question: “What happens to casino profits if the addicts were eliminated?” wrote Christina Binkley in “Winner Takes All: Steve Wynn, Kirk Kerkorian, Gary Loveman, and the Race to Own Las Vegas.” Loveman, a Harvard business school professor before he signed on with Harrah’s, said that when he had chats with gamblers and their casinos, they often told him they were deeply unhappy. “You asked someone how they’re doing, and in a casino they say, expletive,” he said. “I didn’t know how to have that conversation, I didn’t know how to respond” (Binkley, 2008).

He quickly found an answer, and his response was to try to raise his customers’ spirits through human interaction. By doing so, it increased the chances they would stay and gamble more. When players stuck their total reward cards into slot machines, casino officials started tracking their losses in real-time. If they were losing more than the odds suggested they should, a floor person would approach them and give them a token gift (Binkley, 2008).

Employees were given a three-day training program to learn how to “deflect gambler’s misery with empathy,” wrote Binkley, through scripted “have you had fun” remarks that sometimes included tossing them a free e-mail or cash voucher.

Beyond his computer-controlled slots and his finely engineered player rewards program, Loveman learned that sometimes all that is needed to keep the gambler playing and losing is a friendly ear (Binkley, 2008).


Las Vegas

Las Vegas possesses unique qualities with its casino culture embedded into neighborhoods far beyond the tourist-centered Las Vegas strip and into the rest of the Las Vegas Valley. In addition to more than two dozen huge casino resorts on the strip, there are more than 20 full-service casinos specifically designed to lure the “locals” trade as opposed to tourists. There are also a dozen casinos/hotels in the city’s older downtown district, which cater to local gamblers.

This gambling Mecca has become the nation’s problem-gambling capital. In the last several decades, gambling has been absorbed into every facet of life in Las Vegas, and the consequences have been dire. Local residents have found themselves addicted. In turn, this has led to higher gambling-related social costs than anywhere else in the country (Skolnik, 2011).

As voters around the country are deciding whether to ban gambling’s reach, and as the notion that increased availability of gambling leads to more problems, where better to test this theory than Las Vegas? Where better to show what could happen to cities and towns if gambling was legalized to the same extent?

The Las Vegas area population has exploded over the last decade, and residents are inundated with opportunities to gamble. In Clark County, which includes Las Vegas and its suburbs, 14,000 video poker and slot machines operate day and night. There are more than 1,400 gambling venues at restaurants, bars and retailers, at big chain grocery stores and drugstores, at 7-Eleven stores and Kmarts. That is not counting the 1,150 machines at McCarran International Airport (Nevada Gaming Commission, 2011).

Upon arrival, new residents find the highest problem and pathological gambling rates in the country and more Gamblers Anonymous chapter meetings than in any other city, 14 per day on average. There are an estimated 115,000 adult problem and pathological gamblers in Nevada, mostly clustered in and around Las Vegas (NGC, 2011).

Las Vegas and Nevada boasts higher rates of crime, bankruptcy filings, home foreclosures, divorces and suicides than anywhere else in the country (Morgan & Morgan, 2010).

It would not be fair or correct to conclude that the highest problem gambling rates in the country were the direct and sole cause of these problems. For example, authorities have noted that local police departments have been unable to grow as fast as the population, a contributing factor to the high rate of crime. There are other similar, valid, if partial, explanations for each of these indicators, including the notion bolstered by studies of the region that Las Vegas often attracts people inclined to contribute to the social ills (Skolnik, 2011).

Yet in survey after survey, it is become clear that increased problem gambling leads to increased social costs. In dollar terms, a study on the topic co-authored by prominent University of Nevada Las Vegas (UNLV) researchers concluded that problem and pathological gambling among Southern Nevada residents results in costs conservatively estimated to be between $301 million and $469 million per year. There can be little question that Las Vegas is the damaged community, and no doubt at all that the effects of gambling immersion in its culture has played a significant role (Volberg, 2008).

Local casinos offer food and gambling specials on billboards throughout the region. Their ads run routinely on TV and radio, and they contact customers through mailed promotions, especially if they have gambled at one of their properties and joined its free players rewards clubs. Large strip casinos employ these practices as well, targeting the local gambler market using enticements by mail or e-mail.

The most recent comprehensive study regarding the prevalence of problem and pathological gambling in Nevada backs up the accepted notion that the closer people live to gambling outlets like casinos and

the more integrated these casinos are into the communities, the more likely that people will gamble.

Rachel Volberg, a top gambling addiction researcher in Massachusetts, formulated a study in which 2,200 Nevadans were surveyed by telephone. The result showed higher gambling addiction rates in Nevada than in any other state tested. The survey found that one in five adult Nevadans gambled weekly or more often.

Based on the prevailing surveys Paul Berg and others had used in several comparable studies, problem and pathological gambling rates were significantly higher than the national mean. The study found that in 2000, 3.5 percent of the adult population could be classified as pathological gamblers and 2.9 percent as less serious problem gamblers. This was a total of 6.4 percent, or one out of every 16 adult Nevadans. Based on those prevalence rates, about 88,000 adult Nevadans were hooked on gambling at the time. By 2010, that number grew to more than 115,000 people.

Volberg used gambling prevalence screens for her Nevada study. The percentages referred to above were taken from the results of the South Oaks Gambling Screen, which is longer than the standard for problem gambling studies. She also used the newer screen, called the National Opinion Research Center DSM-IV screen for gambling problems, commonly known as NODS.

The results were similar: The current problem and pathological gambling rates in Nevada were a combined 5.1 percent with the end of the NODS, almost twice as high as the national rate of 2.7 percent using the same screen (Volberg, 2008).

In the most significant study to date on the consequences of gambling addiction in southern Nevada, researchers at UNLV in 2003 put a price tag on the social costs that resulted from the abundance of addicted gamblers.

Ninety-nine surveys completed by Las Vegas-area Gambler’s Anonymous members gauged how much gamblers had lost. The researchers broke down the cost of their gambling, including the outstanding debts and bankruptcies filed; crimes committed, including theft and embezzlement; criminal justice system costs resulting from those crimes; lowered work productivity and increased social welfare costs, including food stamps, welfare and unemployment insurance; and the cost of treating their addiction. In Clark County, the social costs for problems in pathological gamblers ranged between $301 million and $469 million dollars. The average Clark County adult incurs gambling losses of $1,511 per year compared with American adult gambling losses averaging $391 per year (Schwer, 2003).

Nevada was rated the most dangerous state in the nation seven recent years in a row, from 2004 to 2010. The rankings from CQ Press are determined using the rates of six different crime categories — murder, rape, aggravated assault, robbery, burglary and auto theft — compared to the national average. In 2010, Nevada’s murder rate was more than six times as high as the safest state, New Hampshire, and it topped the list for robberies, with roughly 250 reported cases per 100,000 residents (Morgan & Morgan, 2010).

There is a proven link between gambling addiction and robbery. A 2004 U.S. Justice Department report studied this link in both Las Vegas and Des Moines, Iowa. Researchers interviewed more than 2,000 arrestees in jails about their gambling habits. They found that a total of 14 percent of the arrestees in Vegas were either problem or pathological gamblers, more than twice as high as a percentage of addicted gamblers in the general population. More than 30 percent of the pathological gamblers arrested in both cities said they committed a robbery within the past year, and nearly a third of them said they had committed the robbery to fund their gambling or to pay gambling debts (McCorkle, 2004).


Along with the high crime rate, Nevada had the highest percentage of home foreclosures in the nation for 2007 through early 2010. The Las Vegas metro area also held the top spot in the country in the last quarter of 2010 for home foreclosures. More than 28,000 housing units in Las Vegas received a foreclosure filing during the quarter. That meant one in 28 housing units received a foreclosure notice, almost five times the national average. (Wargo, 2010).

In a study of home foreclosures, researchers with the FDIC noted the rise in the number of Americans who gamble at casinos, which, “when practiced in excess, can easily lead to insolvency” (Elmer, 1998).

Bankruptcy is another consequence of problem gambling, and Nevada led the nation in bankruptcy filing in the fiscal year ending September 30, 2009, with more than 27,000 filed. Nevadans filed at a rate of 10.49 filings per 1,000 people, more than twice the national rate (Green, 2009).

Also in late 2009, the credit reporting company Trans Union reported that Nevada led the way in the company’s third-quarter 2009 credit card delinquency statistics. That meant more Nevadans per capita were 90 days or more delinquent on at least one of their credit cards, which is greater than anywhere in the country (Green, 2009).

Divorce rates are also higher in states with legal gambling. After Cheyenne, Wyo., Las Vegas is the city where married residents were likely “doomed for divorce,” according to a study reported in 2010 in Men’s Health magazine. The study tallied results based on the state’s lenient divorce laws, the high divorce rate, and the low number of family and marriage counselors in the region. The lifetime divorce rate for problem and pathological gamblers in Nevada is more than twice that of non-gamblers (Associated Press, 2010).

The impact of addicted gambling also hurt families in several other ways, including spousal and child abuse. A 2007 study conducted by psychiatrists in Las Vegas and the University of Iowa concluded that not only are high rates of separation and divorce well documented, but “data from a variety of sources converge to paint a picture of the pathological gambler’s family as disturbed and chaotic, with close relatives frequently suffering from mental health or addictive disorders.” (Black, 2007).

One of the gravest consequences of problem gambling is suicide. For years, Nevada has had the highest rate of suicide in the country, roughly twice the national average. A 2008 study led by a former UNLV researcher confirmed that residents of Clark County, home to Las Vegas, were more than 53 percent more likely to commit suicide than other Americans. When Clark County residents, especially men, left Las Vegas, their likelihood of committing suicide dropped to 40 percent (Wray, 2008).

Factors that may have contributed to this statistic were studied, including the correlation between the suicide rate in Las Vegas and the high rate of gambling as well as the 24-hour access to addictive

substances such as alcohol and drugs, and a lack of mental health resources. They also noted, as other researchers have, that Las Vegas seems plagued with communal problems, and it could be that people who are more impulsive or generally predisposed to risks, including increased threat of suicide, come to Las Vegas (Wray, 2008).

A 2007 study by the Las Vegas Sun, based on data from the Centers for Disease Control and Prevention, show the rate of suicide among senior citizens in Nevada is astonishing. It is not only the highest rate in the country, but nearly three times the national average. From 1999 to 2004, the rates of suicide among those 75 and older were 48 per 100,000. According to the report, 279 seniors committed suicide statewide, and of those, 169 had lived in Clark County. In total, almost two of every three of the 2,661 suicides in the state during the six-year period took place in Clark County (Allen & Richards, 2007).

Gambling has had other harmful impacts on the Las Vegas community. It is one of the several reasons there is such a high rate of local homelessness. “I run across a lot of problem gamblers in the program, and it’s been an issue of increasing concern,” said Alretta Harris, residential work program supervisor with Catholic Charities of Southern Nevada. Harris’s program provides safe housing and meals for 300 able-bodied homeless men as well as counseling and job training. For years, counseling included drug and alcohol addiction sessions three days a week to raise awareness and target those who need help. Harris said she added problem gambling training sessions to the treatment and began referring five to eight men in her program per week to Gamblers Anonymous.

Harris noted that some of the homeless gamblers at her shelter give casinos their temporary Catholic Charities address when they sign up for the frequent player programs. That has led to a stream of free or reduced gambling promotions flooding the facility from local gambling casinos, which make it even more difficult for the men to stay away (Harris, 2011).

There have been few formal studies examining the link between legalized gambling and the payday loan and pawnbroker industries. Critics of all three businesses have long claimed the payday loan and pawn industries feed directly off addicted gamblers eager to pay gambling debts who turn to pawnshops and payday loan stores for easy ways to raise funds and to replenish gambling bankrolls.

Several states have battled the payday loan industry, ultimately banning such stores, because of their exorbitant interest rates and because they target poor customers with little ability to pay off their loans without costly extensions (Skolnik, 2011).

In study after study it has become clear that increased problem gambling leads to increased social costs. There can be little question that Las Vegas is a damaged community, and no doubt at all that the effects of gambling immersion into its culture has played a significant role (Volberg, 2008).

Diagnosing a gambling addiction

An accurate diagnosis requires a complete physical and psychological evaluation to determine whether the person may have a gambling addiction. Since some medical conditions can cause an individual to develop erratic, impulsive behaviors including problem gambling, the examining physician should rule out or exclude these possibilities through an interview, physical examination and applicable laboratory tests, as well as implementing a full mental-health evaluation. A thorough diagnostic evaluation includes a complete history of the patient’s symptoms, and the practitioner might ask the following questions (Edwards & Shiel, 2011):

● How old were you when you gambled for the first time? ● How much money do you lose or spend gambling? ● How much time, how often, and how long each session do you

spend gambling or thinking about gambling? ● What kinds of things do you do to finance gambling? ● Do you feel the need to be secretive about your gambling?

● Once you start gambling, can you walk away? ● Are you compelled to gamble, and do you spend your last dollar or

increase your bet to win lost money back? ● Do you gamble even when you don’t have money? ● Are your family and friends worried about you and your gambling? ● Do you have irresistible urges to gamble?

Arnie and Sheila Wexler (2009), certified compulsive gambling counselors, conduct a series of 23 questions to anyone who may have a gambling problem. These questions are meant to help the individual decide if he or she is a compulsive gambler and whether the person wants to stop gambling. In addition to the questions similar to those above, they include the following:

● Do you find yourself gambling more frequently than you used to? ● Do you ever gamble for more time or with more money than you

intended to?


● Do you have a fantasy that gambling is going to make you rich? ● Do you believe you have superior knowledge when you place a bet? ● Do you lose time from school or work due to gambling? ● Do have intense interest in point spreads or odds? ● Do you make frequent calls to sports phones or lotteries? ● Have you ever bet with a bookmaker or used credit cards to gamble? ● Have your grades or work performance dropped because of

gambling? ● Has anyone ever paid your gambling debts for you? ● Have you ever done anything illegal to finance your gambling? ● Are language or references to gambling part of your vocabulary? ● Do you prefer to socialize with friends who gamble? ● Does anyone in your family have an addiction? ● Have you ever borrowed money to finance gambling? ● Does gambling give you a rush or a high? ● Are you spending more time on the Internet?

● So you play poker on the Internet? ● Have you lied about your gambling to family or friends?

According to the research by Wexler Associates, most compulsive gamblers will answer yes to at least seven of these questions.

The doctor usually asks about alcohol and drug use and whether the patient has had thoughts about death or suicide. The interview often includes questions about whether other family members have had a gambling problem, and if treated, what treatment they received and whether it was effective.

A diagnostic evaluation also includes mental status examinations to determine whether the patient’s speech, thought patterns or memory has been affected, as often happens in the case of many forms of mental illness. As of today, there is no laboratory test, blood test or x-ray that can diagnose this or any other mental disorder (Edwards & Shiel, 2011).

TreatmentCompared with the study of alcohol and drug addictions, problem gambling research is a young field. Though the first Gamblers Anonymous (GA) meeting took place in Los Angeles in 1957, research into problem addiction didn’t begin to really take shape until the early 1970s, when a psychiatrist named Robert Custer, director of the Veterans Administration Addiction Program in Brecksville, Ohio, establish the first in-patient gambling treatment program. One of the first to recognize pathological gambling is a behavioral addiction, Custer believed addicted gamblers engaged in the activity primarily to escape pain. Unlike non-addicted, social gamblers, “the compulsive gambler usually goes alone. He’s isolated. He’s doing it to relieve some kind of psychic pain. Whether he wins or losers, just being in action relieves the pain,” said Custer (Fowler, 1990).

Henry Lesieur co-authored a seminal study on the topic with Custer in 1984, entitled Pathological Gambling: Roots, Phases, and Treatment. He also wrote one of the first books on the topic.

The Problem Gambling Center in Las Vegas often treats gamblers who are near their lowest state of gambling addiction and desperate to stay away from casinos. The center is the busiest gambling treatment center in Nevada, with an intensive outpatient program that costs $145 but usually is waived because of financial hardship.

The program is six weeks long and has had a short waiting list for years. Four days a week, group therapy sessions are led by the center’s clinical director, Robert Hunter, a psychologist, and followed by lectures from Hunter on different topics one day a week. In addition, outpatient program participants must attend at least two GA meetings a week, complete workbooks and questionnaires to aid their recovery, and can request to have a one-to-one session with the counselor. Several other staffers are recovering problem gamblers who have at least two years without a bet. According to the center’s executive director, counselors there treated 250 gamblers in the outpatient program in 2009, and another 660 seniors, in part stemming from outreach programs to senior homes (Hunter, 2003).

About 20 percent of the participants miss the second meeting after showing up at the first, and of those who come back a second time, 33 percent of them leave before the program is halfway finished.

Hunter, a nationally respected expert on the topic of gambling addiction, notes that gambling addicts have distorted senses of control and responsibility. The good news is that with recovery, “appropriate thinking” can take hold. With recovery, he said, “You don’t turn into who you were right before you started gambling. You turn into the person you’re supposed to be” (Hunter, 2003).

Cognitive behavior therapyCognitive behavior therapy aims at replacing negative beliefs with healthy and positive ones as a form of gambling addiction treatment. This therapy focuses on changing unhealthy gambling behaviors and thoughts, such as rationalizations and false beliefs. It also teaches problem gamblers how to fight gambling urges; deal with uncomfortable emotions instead of escaping them through gambling; and solve financial, work and relationship problems caused by the addiction. The goal of treatment is to “rewire” the addicted brain to help the individual learn to think about gambling in a new way, according to Mental Health Department Services (MHAS, 2011).

A variation of cognitive behavioral therapy, called the Four-Steps program, has been used in treatment of compulsive gambling. The goal is to change the thoughts and beliefs about gambling in four steps: relabel, reattribute, refocus and revalue.

Dr. Jeffrey Schwartz outlines the four core steps in recovering from gambling addiction in his book, “Brain Lock.” These four core steps use a variety of psychotherapeutic methods to treat pathological gambling, including cognitive behavioral therapy and rational emotive severity approaches (Schwartz & Beyette, 1996).

Step 1: RelabelRecognize that the urge to gamble is nothing more than a symptom of the gambling addiction, which is a treatable medical condition. It is not a valid feeling that deserves attention.

Step 2: ReattributeStop blaming and try to understand that the urge to gamble has a physical cause in the brain. The individual must learn he or she is separate from the disease of addiction and not a passive bystander. The person must understand that with practice, he or she can learn to control the addiction.

Step 3: RefocusWhen the urge to gamble strikes, shift attention to something more positive or constructive. Plan to do something else, even if the compulsion to gamble is still strong.

Step 4: RevalueOver time, the individual learns to revalue flawed thoughts about gambling. Instead of taking thoughts and feelings at face value, the person realizes these have no inherent value or power. They are just “toxic waste from the brain” (Schwartz and Beyette, 1996).

Individuals learn that seeing a therapist does not mean they are weak or can’t handle their problems. Treatment helps the individual develop tools and support for reframing their thoughts that will last a lifetime to refrain from gambling.

Individuals learn to change their lifestyles and make healthier choices by analyzing what is needed for gambling to occur, work on removing these elements from their lives and replacing them with healthier


choices (Fong, 2010). The four elements of problem gambling to address with clients are:

● A decision – Before gambling occurs, the decision to gamble has been made. If you have an urge to gamble, stop what you’re doing and call someone, think about the consequences of your actions, tell yourself to stop thinking about gambling, and find something else to do immediately.

● Money – Gambling cannot occur without money. Get rid of credit cards, let someone else be in charge of money, have the bank make automatic payments, and keep a limited amount of cash available at all times.

● Time – Gambling cannot occur without time. Schedule enjoyable recreational time that has nothing to do with gambling, find time for relaxation, and plan activities with friends and family.

● A game – Without a game or activity to bet on, there is no opportunity to gamble. Problem gamblers must avoid tempting environments or locations. They must inform the gambling establishments they frequent that they have a gambling problem and ask the casinos to restrict them from betting at their establishment.

Maintaining recovery from problem gambling or gambling addiction depends on why people gambled in the first place. They must address those reasons, such as depression, loneliness or boredom, to maintain recovery and develop alternative behaviors that can be substituted for gambling (Fong, 2010). Some of the reasons that people gamble include:

● To provide excitement, to get a rush of adrenaline. ○ Sample substitute behavior – Participate in a sport or other

challenging hobbies, such as mountain biking, rock climbing or go-kart racing.

● To be more social, overcome shyness. ○ Sample substitute behaviors – Get counseling, enroll in a

public speaking class or join a social group. ● To numb unpleasant feelings, not think about problems.

○ Sample substitute behaviors – Therapy, consult friends and family or a resource help guide such as the Bring Your Life Into Balance toolkit.

● To alleviate boredom or loneliness. ○ Sample substitute behaviors – Find something you’re

passionate about, such as art, music, sports or books, and then find others with the same interests and passions.

● To relax after a stressful day. ○ Sample substitute behaviors – As little as 15 minutes of daily

exercise can relieve stress. Walking, deep breathing, meditation, sauna, steam room, hot bath or massages are relaxation methods.

● To solve money problems. ○ Samples substitute behaviors – Get counseling: honest,

realistic, data-driven analysis should indicate to the individual that gambling has not worked, and the odds are stacked against him or her. Financial counseling for debt and credit management are the appropriate solutions.

In cognitive behavioral therapy people learn that the feelings and urges to gamble are normal. They learn to plan alternatives to gambling as they focus on strategies to build healthier choices, including a good support network that will make resisting cravings easier over time (Petry, 2006). The following strategies can help; tell clients to

● Reach out for support from a trusted family member, meet a friend for coffee, or go to a Gamblers Anonymous meeting.

● Do something else to redirect gambling urges with another activity, such as cleaning the house, going to a gym, watching a movie, or participating in any preferred hobby, sport or activity.

● Postpone gambling by waiting five minutes, 15 minutes, an hour, and keep increasing the time to see how long you can hold out while substituting other activities. Individuals learn that as they wait, the urge to gamble may pass or become weak enough to resist.

● Do a reality check to visualize what will happen if you give in to the urge to gamble; think about how you feel after all the money is gone and you have disappointed yourself and your family again. What other actual consequences will result, for example? Will you be unable to pay the mortgage?

Part of the process of recovery for people is to realize that when a time comes when they are not able to resist the gambling cravings, they cannot use that lapse as an excuse to give up on recovery. Gamblers should be taught that overcoming a gambling addiction is a tough process, and they must not be too hard on themselves. They should understand that they may lapse from time to time, but the important thing is to learn from their mistakes and to continue working toward recovery. (Perkinson, 2001).

Rational emotive therapy

Rational emotive therapy (RET) focuses on helping patients resolve behavioral and emotional problems. RET promotes the belief that when a person becomes upset or depressed, the emotions are caused by his or her own belief system and not the actual event that occurred. Dr. Albert Ellis, creator of RET, says there is an ABC format that can be used to teach people exactly how their belief systems lead to their emotional reactions (Moelker, 2008):A. Something happens.B. You have a belief about the event and situation that has occurred.C. You have an emotional reaction to what your belief happens to be.

This system explains why people have different reactions to the same situation. For example, if two different people are unjustly accused of stealing something at work, both can have completely different reactions. One person might become infuriated at being accused of a crime, while another might become anxious and be more concerned about losing her job. The reasons for the different reactions are based entirely on each individual’s belief about the upsetting event that just happened.

When patients begin RET, they complete an initial assessment with their therapist that usually involves a question-and-answer session. Some of the topics covered include medical and psychological history, family background, employment and education history, and the disclosure of any type of drug and alcohol use or criminal background.

All of these things help therapists chart the best course of action for each patient’s treatment.

RET looks at the relationship between thinking, feeling and action. It is an analysis model that looks at what is going on in people’s lives and strategies and procedures for self-control. It can teach people that they are able to easily influence the situation, such as having a fixed amount of money in their wallet or to be deregistered at the gambling venue. They can gain insight into a certain way of thinking.

When they look at the gambling situation, they identify thoughts or events that preceded the gambling, which led to a bigger need to gamble and the start of the addiction. RET outlines five factors that play a role in gambling (Moelker, 2008):

● Events – The events that preceded the gambling: “Did you feel alone, unhappy, bored, or have a fight or disagreement?”

● Thoughts – What thoughts did the person have during the event: “Did you think if you gambled you would win or feel better?”

● Feelings – These are the decisive factors for the level of the gambling urge.

● Behavior – Gambling. ● Consequences – These may be fights, loss of money, feelings of

guilt or shame, and loss of family or job, to name a few.

By describing these five items, addicted gamblers can gain insight into new ways to respond. They can learn to deal differently with the event


by thinking differently about it and getting different feelings about gambling. By focusing on which feelings are present, they can learn how to react to these feelings to change their behavior. They think of alternatives and strategies to address feelings and use appropriate behaviors and actions to deal with them.

Therapists who use RET in treatment have complete confidence that the sessions will enable these patients to change pre-programmed ways of thinking so they will be able to develop a tolerance for frustration or anger when faced with obstacles in life.

Because of the close interaction between therapist and patient during rational emotive therapy, it is extremely important for patients to choose a therapist with whom they feel entirely comfortable. Challenges will undoubtedly be phased during treatment, and the types of honest exchanges that will resolve them are best handled when there is trust between patient and therapist.

From a clinical standpoint, RET has proven to be effective and efficient at helping patients gain ownership over their emotions. In addition to its use as an individual type of treatment, it has also proven to be effective when used in conjunction with other types of therapeutic practice (Moelker, 2008).

The importance of family in treatment

Compulsive and problem gamblers need the support of their family and friends to help them in the struggle to stop gambling, but the decision to quit rests solely with the gambler. As much as family and friends want the individual to quit gambling and though they suffer from the addiction as well, they cannot make someone stop gambling.

The family or friends of a loved one with a gambling problem may have many conflicting emotions. They may try to cover up for the addicted gambler, spending a lot of time and energy trying to save them from gambling. At the same time, they might be furious at the loved one for gambling again and tired of trying to keep up the charade.

The gambler may have borrowed or even stolen money from family and friends with no way to pay it back. He or she may have sold family possessions, run up huge debts on credit cards, stolen checks, and emptied bank accounts. When faced with the consequences of their actions, gamblers can suffer a crushing drop in self-esteem. This is one reason there is a high rate of suicide among problem gamblers (MHAS, 2011).

When gamblers are feeling hopeless, the risk of suicide is high, and it is important for family and friends to keep communication open with the individual. Family and friends must take any indication, thoughts or talk of suicide seriously and immediately seek assistance from a counselor or suicide prevention organization or hotline. The MHAS offers the following guidelines for family members.

Tools for family members of addicted gamblers: ● Family and friends must start by helping themselves. They have

the right to protect themselves emotionally and financially. They

should not blame themselves or each other for the gambler’s problem. They should seek support to help make positive choices and find balance. Supporters encourage the gambling addicts to get help without losing themselves in the process.

● Don’t go it alone. It can be so overwhelming when coping with a loved one’s problem gambling that it may seem easier to rationalize the gambler’s request to play “this one last time.” Family and friends also might feel ashamed and that their family is the only one that has this type of problem. Reaching out for support can help the family realized that others have struggled with this problem, and they should consider therapy to help with the complicated feelings that arise from coping with a problem gambler.

● Set boundaries in managing money. If a loved one is serious about getting help for problem gambling, another family member should take over the family finances to make sure the gambler stays accountable and to prevent a relapse. This does not mean that that person is responsible for micromanaging the problem gambler’s impulse to gamble. The first responsibility should be to ensure that the family’s finances and credit are not at risk.

● Consider how to handle requests for money and make a plan. Problem gamblers often become very skilled at asking for money directly or indirectly. They may use pleading, manipulation or even threats and blame to get money. It will take time and practice to learn how to respond to these requests to ensure that family and friends are not enabling the problem gambler and are able to keep their dignity intact.

Dos and don’ts for families and friends of the problem gambler

Do: ● Seek the support of others with similar problems; attend self-help

group for families such as Gam-anon. ● Explain problem gambling to the children. ● Recognize the gambler’s good qualities. ● Remain calm when speaking to the gambler about gambling and

its consequences. ● Let the gambler know that you are seeking help because of the

way gambling is affecting family and friends. ● Seek and support treatment despite the time it may involve. ● Take control of family finances; review bank and credit card

statements, and inventory assets.

Don’t: ● Preach, lecture, lose control of emotions or show anger. ● Make threats or issue ultimatums unless they can be carried out. ● Exclude the gambler from activities with family and friends. ● Expect immediate recovery or that all problems will be resolved

when the gambling stops. ● Bail out the gambler. ● Cover-up or deny the existence of the problem to family, friends or

yourself.

Groups can also be very helpful; they offer a medium for advice, feedback and support from individuals who have lived through addiction and the daily work to abstain from gambling (MHSA, 2011).

Medication

Medications for gambling addiction treatment are often from the antidepressant group. SSRIs (serotonin reuptake inhibitors) have proven to be effective in the treatment of gambling addiction that includes mood swings and anxiety.

Mood stabilizers like lithium (Eskalith, Lithobid), and medications used to address addictions like naltrexone (ReVia), antidepressants

like clomipramine (Anafranil) and fluvoxamine (Luvox) have been effective for some patients.

Other medications have been helpful in decreasing the urge to gamble or the thrill involved, including anti-seizure medications like carbamazepine (Tegretol) and topiramate (Topamax) Edwards & Shiel, 2011.


Naltrexone and nalmefene appear to be two of the most promising drugs being studied today. Primarily used to treat alcohol dependence, both drugs have proved more effective than a placebo in treating pathological gambling in three separate randomized clinical trials (APA, 2010).

These drugs are opioid antagonists. “Opioids regulate dopamine pathways in areas of the brain linked with impulse control disorders. The opioid antagonists block opioid receptors in these regions.” (NIH, 2011).

There is an ongoing trial to see whether naltrexone treats pathological gambling among those who develop such disorders, because they had taken a drug for Parkinson’s that has caused addictive symptoms. (Dodd, et al.,) A different trial with naltrexolene, unrelated to Parkinson’s disease, is being conducted and will try to determine whether the drug is effective in a “ real world” clinical setting. That trial is scheduled to be completed in 2012.

Illegal activity and severity

Individuals who engaged in illegal behavior in the year prior to treatment tend to have more severe symptoms of gambling, have more gambling-related debt and have more severe symptoms during treatment compared to people who are not engaged in illegal activity during that time. People who engage in breaking laws the year before treatment began need more intensive treatment for a longer period of time, sometimes even requiring inpatient or residential treatment. Another important fact to consider in treatment is that up to 70 percent of people with this disorder also have another psychiatric problem (Edwards & Shiel, 2011).

It is not enough to just treat the gambling problem. Any coexistent mental-health condition, such as alcoholism or other substance abuse, mood disorder or personality disorder, should be addressed in order to give the addicted gambler the best chance for recovery from both conditions (Petry, 2005).

Though one-third of pathological gamblers may recover from the disease without treatment, the devastation of gambling addiction indicates that positive aspects of treatment outweigh the possible complications resulting from intervention. (Edwards & Shiel, 2011).

One of the challenges of treatment for gambling addiction is that two-thirds of addicts who begin treatment for this disorder discontinue treatment prematurely, regardless of whether treatment involves medication, therapy or both (Edwards & Shiel, 2011).

Although there is no standardized treatment for pathological gambling, many people participate in Gamblers Anonymous (GA). A Gambler’s Anonymous group started on the West Coast in 1949. In 1957, the modern Gamblers Anonymous was established to provide a support group as a form of gambling addiction help.

The National Council on Problem Gambling (NCPG) was founded in the year 1972. Robert Custer, MD, established the first treatment program for pathological gambling at Brecksville Veterans Administration. The Journal of Gambling, known earlier as the Journal of Gambling Behavior, was first published in 1985, edited by Henry Lesieur, PhD., Gambler’s Anonymous offered widespread gambling addiction help. The various chapters of this gambling addiction help

and support system are spread across the United States and help in the diagnosis and treatment of the problem of gambling (Skolnik, 2011).

The approximately 8 percent, one-year abstinence rate that GA intervention tends to produce is improved when the program is combined with psychotherapy administered by a trained professional. That seems to be particularly true when cognitive behavioral treatment is a psychotherapy approach that is used by the practitioner (Edwards and Shiel, 2011).

Dr. Robert R. Perkinson developed one treatment program based on aspects of Gambler’s Anonymous combined with cognitive behavioral therapy, inpatient and outpatient treatment. He is the clinical director of Keystone Treatment Center in Canton, S.D., and has been treating alcoholics, addicts and pathological gamblers for more than 30 years. He is the author of “Chemical Dependency Counseling: A Practical Guide, 2nd edition.” (Perkinson, 2001).

This program incorporates a 12-step recovery in a straightforward approach that uses workbooks and counseling to guide individuals to accept responsibility and understand their emotions and behavior. The program progresses from the beginning of their addiction to the end of treatment and development of a personal recovery plan. His patient workbook, “The Gambling Addiction Patient Workbook,” was written in 2003 and reports 90 percent of patients who worked this program stay free of their addiction.

Perkinson notes that gambling addiction is a disease and that patients need not feel bad about themselves. He explains that the addiction is a chronic relapsing brain disease, and the brain has been hijacked by the illness. He stresses that though the program is not hard, the individual “will be in a life-and-death struggle, and the war will be played out inside of the patient’s mind, body, and spirit.” He tells patients they are in a fight for their life, but they are not alone because he will guide them through the steps to win their battle against addiction (Perkinson, 2001).

The final steps in the program address relapse prevention and the development of a personal recovery plan. Perkinson notes that many patients have problems with relapse in early recovery.

Preventing relapse

About two thirds of patients coming out of addiction programs relapse within three months of leaving treatment (Hunt, Barnett, and Branch, 1971). Frances, Bucky and Alexopolis (1984) found that people who go through treatment ultimately achieve a stable recovery. Relapse prevention is a daily program that can prevent relapse and can stop a lapse from becoming a disaster.

One prevention program uses a combination of the models of Gorski and Miller (1986) and Marlatt and Gordon (1985). This uses the disease concept model and a cognitive behavioral approach. Relapse warning signs include:

● Apprehension about well-being. ● Denial. ● Adamant commitment to stop gambling. ● Compulsive attempts to impose abstinence on others. ● Defensiveness. ● Compulsive behavior. ● Impulsive behavior.

● Loneliness. ● Tunnel vision. ● Minor depression. ● Lots of constructive planning. ● Plans beginning to fail. ● Daydreaming and wishful thinking. ● Feeling that nothing can be solved. ● Periods of confusion. ● Irritation with friends. ● Quick to anger. ● Irregular eating habits. ● Listlessness. ● Irregular sleeping habits. ● Progressive loss of daily structure. ● Periods of deep depression. ● Irregular attendance at meetings. ● An “I don’t care” attitude.


● Open rejection of help. ● Dissatisfaction with life. ● Feelings of powerlessness and helplessness. ● Self-pity. ● Thoughts of social gambling. ● Conscious lying. ● Loss of self-confidence. ● Unreasonable resentments. ● Discontinuing treatment. ● Loneliness, frustration, anger or tension.

● Start of controlled gambling. ● Loss of control.

Individuals are instructed to check for each warning symptom daily and are given steps and a plan to follow if signs of relapse are detected.

Marlatt and Gordon (1985) found that relapse is more likely to occur in certain situations. These situations can trigger relapse, and they found that people relapse when they could not cope with life situations except by returning to their addictive behaviors. Individuals are taught in treatment to develop coping skills for dealing with each high-risk situation.

Negative emotionsAbout 35 percent of people who relapse do so when they experience negative feelings and are unable to cope with them. Most feel angry or frustrated, but some feel anxious, bored, lonely or depressed. Almost any negative feelings can lead to relapse if the individual does not learn how to cope with the emotion. Individuals are encouraged to do an inventory daily of any feelings that could lead to a relapse. They

develop coping skills for dealing with each feeling that makes them feel vulnerable then they develop a specific plan of action.

The plan may include talking to a counselor or calling a friend in the program who can help them with coping strategies to resist gambling. Substitute behaviors may include reading some recovery material or any other action or activity specific to the individual to help them deal with negative emotions.

Social pressureMarlatt and Gordon (1995) found that about 20 percent of people relapse in social situations. Social pressure can be direct, where someone directly encourages the individual to gamble, or it can be indirect, such as a social situation where people are gambling. Both of these situations can trigger intense craving that can lead to relapse. For example, more than 60 percent of alcoholics relapse in a bar.

● High-risk friends ○ Certain friends are more likely to encourage the addict to

gamble. These people do not necessarily want to hurt them, but they want them to relax and have a good time. They often want their old friend back and do not understand the nature of their disease. They may be pathological gamblers themselves and are in denial.

○ The recovering gambling addict is asked to make a list of high-risk friends who might encourage them to gamble and to develop a plan if these friends suggest gambling. The individual is encouraged to set up a situation where the whole group encourages him or her to gamble. After that exercise, the person discusses his or her feelings and develops strategies to address the situation and ways to say no.

● High-risk social situation ○ Certain social situations will trigger the urge to gamble, and

are usually situations in which the individual has gambled in the past. Certain bars and restaurants, the race track, a particular part of town, certain music, athletic events, parties, weddings and family get-togethers are some of the situations that can trigger intense cravings to gamble. The individual is encouraged to make a list of social situations where they might be vulnerable to relapse.

○ People in early recovery are instructed to avoid these situations and friends. If they have to attend a function where there will be gambling, they are instructed to take someone with them who will support them in this situation and make sure they have a way home. All individuals are instructed and prepared

to leave if they feel uncomfortable and to avoid all situations where their recovery feels at risk.

● Interpersonal conflict ○ About 16 percent of addicts relapse when they are in conflict

with another person. They may have a problem with someone and have no idea how to cope with the problem. The stress of the situation builds and may lead to gambling. This conflict usually happens with someone the person is closely involved with, such as a spouse, child, parent, sibling, friend, boss or another person in a close relationship.

○ Individuals are taught that they must have a plan for dealing with interpersonal conflict with anyone, even a stranger. Communication skills are important in treatment to help the individual communicate when under stress. Individuals learn and practice the communication and interpersonal skills.

○ Individuals learn that if they can stay and work out the conflict, that is the best strategy. If they cannot work it out, they are instructed to leave the situation and get help. They may go for a walk, run or a drive to stop the conflict. They practice strategies to cool down and to deal with the situation, and if they cannot do so, they will contact someone for support.

● Positive feelings ○ About 12 percent of people relapse when they are feeling

positive emotions. They may have gambled to celebrate, and that has become such a habit that when something good happens, they immediately think about gambling. Individuals need to be ready to react appropriately when they feel like a winner, and this may be at a wedding, a birth, a promotion or any event where they feel good.

○ The individual is reminded to look at the reality of gambling by thinking about the negative consequences that gambling has caused them. As with negative feelings, they are asked to list the positive feelings that may make them vulnerable to relapse.

Planning for the first temptation and its consequencesGamblers are counseled to look at the early stage of their gambling and compare it to the late stages of gambling addiction. They learn the very things they were gambling for in early gambling resulted in the opposite result in late gambling (Schwartz &Beyette, 1996).

For instance, if they were gambling to be more popular, in the end they were feeling more isolated and alone. If in early gambling they were feeling brave, in late-stage gambling they were feeling afraid. If

in early gambling they were feeling smart, in late-stage gambling they were feeling stupid and worthless.

By comparing the characteristics of their early gambling and late-stage gambling, they are looking at how the illness relates to their thinking process and perceived and actual consequences of their addiction. By looking at the second list of late gambling characteristics they are able to see the negative consequences that come from gambling (UCLA, 2010).


Hunt and colleagues (1971) in a study of recovering addicts found that 33 percent of patients lapsed within two weeks of leaving treatment; 60 percent lapsed within three months; and at the end of eight months. 63 percent had lapsed. At the end of 12 months, 67 percent had lapsed.

Individuals are taught that a lapse is it not a failure in recovery but is viewed as a mistake that the individual can learn from. They need to examine exactly what happened and get back into recovery. A lapse is an emergency that requires immediate action to prevent it from becoming a full-blown relapse. People are instructed to

carefully examine why, when and how the lapse occurred and use the opportunity to review their new skills and plan of action to recover from the lapse.

They are instructed they cannot do this alone and must depend on their counselor, family, friends, or individuals within their recovery group to develop a new treatment plan that may involve outpatient care. Individuals might need inpatient treatment and are encouraged not to be alone after this time.

The behavior chainTo understand the sequence of behavior that affects their gambling addiction, people must identify the triggers and external events that start the behavioral sequence. After the trigger, thinking happens very quickly, and they may not have time to stop and focus. The thoughts that trigger feelings may give persons energy and direction for action. Next comes the behavior or the action initiated by the trigger. Finally there is always the consequence for the action (Fong, 2010).

The following describes a behavior chain:Trigger → thinking → feeling → behavior → consequences

Here are examples of behavioral chains and how they work:1. On the way home from work, Susan, a recovering gambler, passes

the convenience store (trigger). She thinks, “I’m feeling in control, and I think I will buy some lottery tickets just for fun,” (trigger initiates thinking). Susan wants to gamble and feels a craving (thinking initiates feeling). She turns into the convenience store and buys a scratch-off ticket, then four more (feeling initiates the behavior). Susan lapses (the behavior has a consequence).

2. It is midnight, and Tom is not asleep (trigger). He thinks, “I will gamble just a little so I can sleep,” (thinking). He feels anxious about not sleeping two nights in a row (feeling). He gets up, goes to the computer and enters his favorite online gambling site (behavior). He loses a large amount of money and is so depressed and exhausted that he cannot go to work the next morning (consequences).

Individuals learn that at every point along the behavioral chain they can work to prevent a lapse or relapse. They begin by examining triggers carefully to determine what environmental events could lead to gambling.

They learn to re-examine high-risk situations to determine what people, places or things make them vulnerable to lapse or relapse. In

this way they can stay away from these triggers as much as possible, and if the trigger occurs, they are prepared to use their new coping skills and substitute behaviors (Fong, 2010).

To prepare for continued recovery, they develop a daily relapse prevention program, which increases their chances of success. This plan includes evaluating their recovery daily and keeping a journal and prevention inventory for continued progress.

This inventory assesses: ● Relapse warning signs. ● Feelings about themselves and others. ● Sleeping, eating, exercise and relaxation habits. ● Progress in the total recovery program.

The book “Twenty-Four Hours a Day” (Walker, 1992) is a resource that includes an example of a daily prevention inventory. Individuals are instructed to complete the inventory every day and review the results along with their treatment plan and write in a journal. This will help them reflect on how much they have changed throughout the program.

At this stage in the treatment they are asked to list 10 reasons why they want to stay free from gambling and to review this list and carry a copy with them at all times.

The final step in the program is the development of a personal recovery plan. This includes a treatment plan for continued abstinence from gambling and includes a detailed list of support for recovery, including daily actions to take to remain free from gambling.

The individual signs a contract of commitment, developed with the counselor and other family and friends in the support team (Perkinson, 2001).

Stages of recovery

Custer outlines three stages in the gambling recovery. Once gambling addicts have reached the lowest stage of addiction, which involves despair, thoughts of suicide, possible arrests, drug and alcohol addiction, and emotional and physical breakdown, they are at the stage where they will admit they have a problem and seek help.

The first phase of recovery is labeled the critical stage. This stage is characterized by the following:

● The person is dealing with withdrawal symptoms but has an honest desire for help.

● The person begins to anticipate possible behavioral change and will conduct a personal inventory.

● The person’s thinking becomes clearer. ● The person is able to focus on reality to stop gambling. ● The person begins the process of creative problem-solving. ● The person may begin to address his or her spiritual needs.

The next stage of recovery is known as the rebuilding stage and is characterized by the following:

● The individual can begin an appropriate decision-making process. ● The individual will often return to school or work. ● The individual has improved family relations. ● The individual develops non-gambling friends.

● The individual’s grades and work performance improve. ● The individual has new recreational interests. ● The individual builds self acceptance. ● The individual develops goals and clarifies values. ● The individual makes amends for the harm he or she has caused. ● The individual’s self-respect begins to return. ● The individual works to resolve legal problems. ● The individual begins to trust self. ● The individual is less impatient with his or her situation. ● The individual begins to feel renewed trust from family and friends.

The final phase of recovery as outlined by Custer is the growth stage, characterized when the gambler does the following:

● Spends more time with family. ● Is less sensitive and more outgoing. ● Learns and practices stress reduction strategies. ● Finds the desire to gamble decreases. ● Feels less anxiety. ● Faces problems directly and promptly. ● Is capable of giving affection. ● Gains understanding of self and others. ● Is willing to help others. ● Reaches the final stage, the gambling-free way of life.


Principal errors in thinking among gamblers

One way to prevent and control gambling is to alleviate fallacies in thinking (Jordan, 2009). Gamblers must evaluate their patterns of thinking to determine whether they are based on realistic odds. The following are some concepts commonly misunderstood by a compulsive gambler:

● Independence of turns ○ It is not unusual for gamblers to think in terms of winning

streaks, which motivates them to continue gambling. They might say, “I will definitely win today, I am on a winning streak,” or “I will not place a bet on that machine, it’s on a losing streak.” For example, when they get three wins in a row, they interpret it as a strong likelihood that the next bet will win.

○ Sometimes gamblers interpret a fixed session of losses as one that would result in a win soon. They may say, “It’s been even-numbers that appear all night, so chances are high that next role will be an odd number.” They may even justify this thought statistically, thinking if they have been getting bad roles for a while, chances are the next one will result in a win. This assumes that each of the turns would subscribe to the law of averages.

○ This kind of thinking violates the principle of the independence of turns. Independence of turns means that events are independent of each other; each is considered unique and has no links to previous and consequent events. Thus there is no such thing as lucky streaks or catching up on previous losses.

○ Each bet has a 50-50 chance of winning. Independence of turns is an essential condition of games of chance. In order to be unpredictable and to obey the rules of chance, all gambling games are structured in a way that each turn is an independent event and in no way determined by the results of the previous turn. This independence of events, or absence of a link between events, makes predicting the next result impossible.

○ Thus, gamblers can never exert any control over the game. ● Illusions of control

○ Most gamblers believe they accumulate experience and learn from their errors when gambling. In truth, this feeling of personal efficacy is a considerable handicap, and gamblers

who believe that their actions influence their chances of winning are victims. They maintain the illusion that they will beat the industry by defying the negative winning expectancy by recouping their losses (Jordan, 2009).

○ Gambling activities are not games of skill; no mental or physical skills are necessary when it comes to betting. However, the majority of gamblers believe that it is possible for them to acquire some form of mastery.

○ Familiarity is an important factor in the illusion of control. But when people familiarize themselves with the task determined by chance, the more they have the impression they are able to control the situation. The amount of direct exposure to a situation increases the degree of perceived control.

○ A number of studies have demonstrated that when people have the opportunity to discuss the degree of risk they take, they take greater risks when they make their decisions alone. Wallech explained that this increase in risk-taking is a group process in which the individuals share responsibility, and each group member feels less individually responsible for the risk-taking behavior. As a result of the group discussion, a tolerance for risk-taking increases (Wallech, 2011).

● Superstitions ○ Another common error in thinking among gamblers is the

belief in superstitions. Often superstitions support a gambler’s illusion of control by making him think that a ritual can increase his chances of a win.

○ The next obvious step would be to address these principal errors in thinking through a form of therapy, such as cognitive behavioral therapy, that focuses on thought processes. This could lead the addicted or potential addicted gambler to identify fallacies in thinking, which are directly related to the person’s views on winning. Since these errors in thinking contain concepts commonly misunderstood by the gambler, this may provide a cognitive basis to deal with the realities of gambling to change his or her thought patterns and develop appropriate strategies for prevention (Jordan, 2009).

Efforts to restrict online gambling

With the increasing incidence of online gambling, a commercially produced computer application has been developed to block access to online gaming. GamBlock has been available since 2000 to help problem gamblers avoid the unrestricted online gambling.

GamBlock uses a system that continually locates and blocks new gambling sites and software as it is developed. It does not require constant updating of website lists and claims to eliminate all access to online gambling.

GamBlock cannot be removed and could be used by treatment facilities, hospitals, correctional facilities, schools, libraries, government buildings and other institutions. This system is installed to ensure that online gambling cannot be conducted from their facility by staff, patients or visitors.

This system could be effective in situations where only one computer is available, such as a home computer or controlled therapeutic setting, to give computer access to an individual in a treatment and recovery setting. It would not address the underlying issues involved in a gambling addiction nor serve as a replacement for treatment.

The role of the states in gambling addiction

In his book “High Stakes, The Rising Cost of America’s Gambling Addiction,” Sam Skolnik points to individual states as “the other gambling addicts” (2011).

He begins with an example of JoDean Joy, a housewife and mother of five who grew up on a farm outside Miller, S.D. She became the state’s leading citizen advocate against gambling because of the anguish it caused her family.

Her son-in-law, an Iowa accountant named Bob Phillips, had embezzled millions of dollars from clients to support his gambling addiction. Phillip’s crimes had a devastating impact on her daughter’s

family, and friends and Joy decided to lead the fight against legalized gambling, which was spreading rapidly through her state.

Joy noticed lots of changes after gambling exploded in South Dakota in 1989, the year she learned of Phillip’s crimes:

● There were stories she heard from teachers about students no longer having money for clothes or even meals because their parents had gambled away their paychecks.

● There was a friend of hers, a banker, who skimmed money off clients’ accounts so he could rush back to the video lottery terminals.

● There were business owners struggling to overcome decreased sales and unpaid debt.


And those were just her hometown examples.

Two decades since gambling businesses were legalized, South Dakota and many of its residents have become hooked on gambling. Deadwood now has more than two dozen casinos, and the establishment collectively earned total gross revenues of just over $100 million in fiscal year 2009, three times the revenues earned in 1991.

The profits produced by South Dakota’s nine Indian casinos are not publicly known. The National Indian Gaming Commission does not make tribal-specific or state-specific confidential financial information available to the public.

However, according to a 2004 report sponsored by the South Dakota commission on gaming, the state’s Indian casinos generated about $75 million in profits in the previous year (Cummings Associates, 2004).

In 2009, video lottery terminals spread throughout the state, earning $219 million for the state (South Dakota Annual Report, 2009). The gambling revenues comprised 13 to 18 percent of the states revenues, second only to Nevada (Prah, 2007).

As late as 2010, 10 Indian casinos to be located in the Sioux Falls area were in the planning stages. They were proposed to compete with the $120 million commercial casino being built just over the Iowa border (Skolnik, 2011).

Within two years of legalized gambling in South Dakota, gambling addiction had already become one of the leading causes of personal and business bankruptcy filings. One report noted that before 1989, bankruptcies in South Dakota were not caused by gambling (Nelson, 1993).

Jeff Bloomberg was the state attorney for Lawrence County, which includes Deadwood, from 1986 to 1995. The year before he left office, he testified before a congressional committee that statistics from his office showed there had been an increase in reported child abuse and neglect cases since the Deadwood casinos opened, and he listed a number of tragic criminal cases stemming from the newly available gambling.

Crimes ranged from a manager of a pizza restaurant who embezzled $45,000 to a U.S. Air Force sergeant, hooked on slot machines, who killed a casino operator in an attempt to recover a few bad checks he had passed. Both men previously had no criminal records (Goodman.1995).

Bloomberg currently serves as commissioner of the Bureau of Administration, which handles purchasing for South Dakota’s state offices. He said the state has become thoroughly dependent on gambling revenues. “To be honest with you, if we didn’t have that money, we’d be hurting; we wouldn’t be able to make it,” he said. “The general attitude is, plug your nose and live with it” (Goodman, 1995).

Over the last two decades, states around the country have been turning toward the South Dakota model of legalized gambling inundation in increasing numbers. The main reason for the push is clear: gambling revenue to shore up budget deficits, allow for reduced taxes and pay for important programs from public works to public education.

Collectively, these budget shortfalls are gigantic, and by the end of fiscal year 2010, state governments around the nation were looking at an expected $127 billion fiscal hole (Conner, 2010).

Despite adverse consequences in the form of higher addiction rates and increased social costs, gambling repeatedly has been deemed by state-level politicians to be in the public interest. The recession of the late 2000s only aided their efforts. Desperate officials are turning to gambling as an economic cure-all. They see no other form of revenue generation as tempting or as politically feasible. And although voters are still generally wary of gambling, the closer the proposed casino is to their home, the more wary of it they are. The relentless efforts of the gambling supporters are beginning to wear them down (Skolnik, 2011).

Proponents know that they have time and money on their side. When gambling expansion proposals get shot down, as voters have been doing slightly more than half of the time over the last several

years, advocates simply reintroduce the idea before the next election. Expansion supporters know that when gambling becomes legalized, it’s virtually impossible to get rid of, in significant part because of voters’ fears of increased taxes or reduced government services (Skolnik, 2011).

This cycle is aided by the states’ sense of competition with one another. It’s a phenomenon that has reached epidemic proportions in the Northeast as even the possibility of increasing gambling in some states has caused envy among their neighbors. States are anxious to regain what they consider rightly to be theirs, the gambling losses of their own residents.

New Jersey has casinos but also wants legalized sports betting. Pennsylvania, Delaware and Maryland have slots parlors or “racinos,” race tracks with slot machines, which Pennsylvania and Delaware have turned into full-fledged casinos with table games (Goodman, 1994).

Connecticut’s two mammoth and hugely profitable Indian casinos, Foxwoods Resort Casino and Mohegan Sun, have benefited from gamblers who live in neighboring states. This has spurred officials in New York, Rhode Island, Massachusetts, New Hampshire and Maine to fast track their casino proposals. The list goes on, and the Northeast is the most glaring example of these regional contests to attract more gamblers to their states.

This trend has been in existence since the early 1990s, but it picked up significant steam when the economic downturn took hold in 2008 (Goodman, 1994).

Repeated studies have shown that newly legalized gambling opportunities create new gamblers, it doesn’t simply siphon off those who gamble at other legal venues or who gamble illegally. People who didn’t gamble before begin to do so. A small subset of those gamblers becomes addicted (Cummings Associates, 2004).

The overall gambling market, including legal and illegal wagering, increases as casinos increase. The U.S. Department of Justice, among others, has found that as legalized gambling grows, the amount of illegal gambling grows along with it. Criminals, including in some cases organized crime syndicates, take advantage of the new gambling market by offering gamblers different types of competition as well as credit and loans at usurious rates (Morgan & Morgan, 2010).

The arguable downside to legalized gambling is the increased social costs the whole community pays. One of the most comprehensive studies is by Baylor University economist Earl Grinols. In his 2004 book, “Gambling in America: Cost and Benefits,” Grinols found that addicted gamblers cost the United States between $32.4 and $53.8 billion per year, or an average of $274 per adult. That’s about 40 percent of what drug abusers cost the country (Grinols, 2004).

Iowa state Rep. Kraig Paulsen, an expansion opponent, said in early 2010, “Absolutely we’re addicted to gambling dollars.” He noted that his state currently receives about $300 million a year from the industry. Further, he noted, “With the current budget, we couldn’t be close to being balanced without that money”(Crumb, 2004).

Expansion proponents are quick to note their concern about gamblers who develop problems because of the new casinos, lotteries or racinos they are promoting. That’s why these officials usually agree to set aside a small portion of the profits for problem gambling, public awareness and treatment programs. One could conclude that what they’re actually saying is, “We know we are willfully creating a new subclass of addicts in our community, but we promise we’ll try to fix them and mitigate the damage” (Skolnik, 2010).

Gambling has played an important role in how our local governments raised revenue since before America’s declared independence. Though it may be difficult to imagine in the current gambling environment, there have been points in our history when prohibition forces destroyed growing periods of lotteries, riverboat gambling and small


private casinos, only to see those prohibitions eroded through more legalized gambling.

This is what gambling historian and legal expert I. Nelson Rose refers to as “cycles of complete prohibition to complete permissiveness and back again.” He calls these periods “America’s waves” of gambling (Rose, 2010).

The timing of these gambling revivals was no accident; bad times have always spurred legalized gambling. Citizens, not to mention their elected representatives, have repeatedly been willing to fund tax cuts and prop up sagging state governments by increasing revenues from legalized gambling (Sauer, 2010).

Shifting moral perceptions of gambling and its place in society, similar to changing ideas about alcohol and drugs, also has played a big role. ”The anti-gambling prohibitions epitomize the traditional approach taken by American laws. These laws are not only designed to protect people from themselves, they are part of a greater moral framework, designed by policymakers as a reflection of an ideal society,” Rose writes. The Victorian morality that says nothing is permitted is replaced by the belief that everything is permitted so long as you do not hurt another person, and gambling is the “least harmful of the victimless crimes” (Rose, 2010).

Recent national surveys send mixed signals on how Americans view gambling and whether they want it to be part of their lives are in their neighborhoods. According to 2010 Gallup poll of about 1,000 American adults, 61 percent of those polled found gambling to be “morally acceptable” behavior; 34 percent viewed it as “morally wrong” (Saad, 2010).

The overall percentage of those who viewed gambling as morally acceptable has remained steady since 2003. The same is true for the slightly higher percentage of American adults, about two out of three, who told Gallup in 2003 and 2007 they gambled at lease once in the previous 12 months. In the 2003 survey, 6 percent of those questioned said they gambled more than they should. Likewise, 6 percent said gambling had been a source of problems for their families and them (Jones, 2004).

In a 2010 poll conducted by the Saint Consulting Group, 72 percent of the Americans polled said they were against a casino being built in their community. “The Saint Index 2010 results suggest the prolonged economic downturn is undermining America’s ‘not in my backyard’

attitude,” with fewer respondents rejecting the casinos in 2010 as compared to the 2009 poll. In 2010, 37 states sought to expand gambling to some degree, and Hawaii debated whether to introduce legalized gambling for the first time (SCG, 2010).

Whether legalized gambling is a smart economic move for states raises big concerns for national policy. Robert Ward, deputy director of the Nelson A. Rockefeller Institute on government, noted how states freely express concerns about people engaging in other habits widely considered to be unhealthy and offer programs to reduce the activity. With gambling, it’s often the opposite. “It’s ironic that states are using tax policy to reduce cigarette smoking and discourage unhealthy eating at the same time they are promoting more gambling and the more social pathology,” said Ward in an e-mailed response to questions. “It’s very hard to conclude that every marginal increase in state-sanctioned gambling pulls in someone who otherwise would not be involved in illegal gambling. In other words, the states almost certainly are creating new gamblers, and a certain number of those gamblers are finding out firsthand what addiction is all about” (Fajt, 2010).

At the new slot parlors and racinos that the governor of Pennsylvania fought for, new gamblers are mostly local, and many are exhibiting symptoms that reflect addiction. The revenue comes mostly from local “low rollers,” casino president David Jonas said at a Pennsylvania Gaming Congress in early 2010, most of whom live within 20 miles of the facility. Often, they show up 150 to 200 times and usually lose small amounts (Fajt, 2010).

During the unseasonably hot summer months of 2010, seven different customers left children, including a 15-month-old, unattended in their cars so they could run in and feed the slots for a while and play some roulette (Kinney, 2010).

In September, several state and local politicians, a police director and casino executive held a news conference. They said enough was enough: tough action was needed and proposed making a felony out of stranding children in vacant cars to gamble. Three hours after the press event ended, a man shut his 12-year-old grandson in an SUV for a half hour without keys, air-conditioning or water to play at a casino just outside Philadelphia. It was 94 degrees outside. Luckily, the police were able to intervene in time, and when the police located the man, he told them he was $100 up at the time and did not want to leave (Kinney, 2010).

The federal role and a look forward

Keith Wythe, executive director of the National Council on Problem Gambling, found himself at odds with both sides of pro- and anti-gambling advocates. A powerful segment of the gambling industry has taken issue with the Comprehensive Problem Gambling Act. For example, a bill before Congress that Wythe and the counsel energetically promoted would grant the federal government millions to fund research and problem gambling, effectively challenging the industry’s dominant position as the funder of the majority of such studies conducted over the last decade. In an October 2010 interview, Wythe noted that there’s not a lot of communication these days between his group and the American Gaming Association that come out against the bill (Skolnik, 2011).

At the same time, Wythe has had non-productive relations with some anti-gambling activists who claim he’s insufficiently attentive to the dangers of legalized gambling expansion.

Wythe makes it clear that the council is the chief national advocate of programs and services to assist problem gamblers and must not be compromised. He said, “We have to make sure we’re not bought and paid for” by pro-or anti-gambling interests” (Skolnik, 2011).

The Comprehensive Problem Gambling Act would amend the Public Health Service Act to include new programs run through the Substance Abuse and Mental Health Services Administration (SAMHSA) to

research, prevent and raise awareness of the harmful consequences of problem and pathological gambling. Among other things, SAMHSA, a division of the U.S. Department of Health and Human Services, provides grants for alcohol, illegal drugs and tobacco prevention and treatment programs.

The act would cost $71 million over five years, at about $14 million per year. The largest amount would go toward funding problem gambling prevention and treatment programs sponsored by state, local and tribal governments as well as nonprofit groups. Another $4 million per year would go toward funding a new national program of research on problem gambling (Christiansen, 2003).

Finally, $200,000 per year would kick-start a national public awareness campaign through promotion of public service announcements. As Wythe and Tim Christiansen, president of the Association of Problem Gambling Service Administrators, have noted, not a single cent of the $3.55 trillion budget currently is dedicated to problem gambling, and not a single federal employee has problem gambling as part of their job.

This is the case despite the fact that the federal government, through SAMHSA, spent $2.5 billion in 2010 alone on programs related to the prevention and treatment of the abuse of substances such as alcohol, tobacco and legal drugs, according to the agency’s website (SAMHSA, 2010).


Largely due to the efforts of the national counsel, momentum for the Problem Gambling Act has picked up in Congress. During the first nine months of 2010, Wythe and a team of national Council grassroots lobbyists have met with officials from 278 house offices and 76 Senate offices. By October 2010, 72 House members agreed to become cosponsors, and the bill was introduced for the first time in the U.S. Senate where four cosponsors also have signed on. The measure has picked up bipartisan support in both chambers, although Democratic co-sponsors outweigh Republicans by about a four-to-one margin (Skolnik, 2011).

According to Wythe and Christiansen, the federal government needs to follow the lead of the states that recognize because they’re profiting

from an addictive activity they sanction, they owe a responsibility to those who became addicted and need to try to prevent others from developing problems (SAMHSA, 2010).

Since 2001, the number of states that offer at least some funding for programs to prevent and treat problem gamblers has grown almost three-fold from 13 that year to 38 in 2010, according to Christensen’s group. Still, other data suggest the amount of public funds devoted to problem gambling services at the state level, a total of $13.5 million in 2010, about half of which goes to programs that subsidize treatment programs, is relatively small (AGA, 2010).

Resources for information

● American Psychological Association - [email protected] ● Gamble Anonymous - [email protected] ● Compulsive Gambling Center http://www.lostbet.com ● Game-Anon International - www.gam-anon.org ● United States Gambling Hotline - 1-800-522-4700 ● UCLA Gambling Studies Program - http://www.

uclagamblingprogram.org

● Massachusetts Council on Compulsive Gambling - http://www.masscompulsivegambling.org

● National Council on Problem Gambling - www.ncpgambling.org ● Debtors Anonymous - http://www.debtorsanonymous.org ● Ernie and Sheila Wexler Associates - www.aswexler.com

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GAMbLING ADDICTIoN: ETIoLoGy, TREATMENT AND PREVENTIoNFinal Examination Questions

Select the best answer for each question and then proceed to SocialWork.EliteCME.com to complete your final examination.

1. Harmful effects of compulsive gambling on the individual include financial problems ranging from high debt, bankruptcy, poverty, legal problems, theft, prostitution, and attempting or completing:a. A gambling questionnaire.b. Suicide.c. Quitting “cold turkey”.d. A battery of tests.

2. As of 2010, a variety of gambling activities have been legalized everywhere in the United States EXCEPT:a. North Dakota and Florida.b. Michigan and California.c. Iowa and South Dakota.d. Utah and Hawaii.

3. The American Psychological Association has proposed a reclassification of the diagnosis criteria for gambling addiction in the DSM-5. All of the following considerations are included EXCEPT:a. After losing money gambling, the individual returns another

day to get even (“chasing” one’s losses).b. The individual has repeated unsuccessful efforts to control, cut

back or stop gambling.c. The individual lies to family members, therapists or others to

hide the extent of his or her involvement with gambling.d. The individual has been convicted of illegal acts, such as

forgery, theft, or fraud to finance gambling.

4. Which of the following is a fact about gambling addiction and problem gambling often held by gamblers and their family and friends?a. Partners of problem gamblers often drive the person to addiction.b. Someone has to gamble every day to be a problem gambler.c. Bailing the gambler out of debt may actually make matters

worse by enabling problem-gambling behaviors to continue.d. Problem gambling is not really a problem if the gambler can

afford it.

5. Signs and symptoms of pathological gambling include:a. Feels guilty or remorseful after gambling.b. Relives past gambling experiences.c. Has failed efforts to cut back on gambling.d. All of the above.

6. The following statements about prevalence rates of gambling addiction are true EXCEPT:a. Asian Americans gamble at a higher rate than Americans with

other ethnic backgrounds and suffer as problem gamblers at a higher rate.

b. Native Americans have higher gambling addiction rates than Caucasians.

c. The middle-aged are especially at risk for developing gambling problems.

d. Individuals over 65 are the fastest-growing group to become addicted to gambling.

7. The following statements are true about risk factors for gambling addiction EXCEPT:a. Certain personality traits, such as being highly competitive,

restless, easily bored and ADHD, may be risk factors for developing a gambling addiction.

b. Those who experience drug and alcohol dependence are at risk for gambling addiction.

c. Family history has no correlation to the risk of developing a gambling addiction.

d. Parkinson’s disease medications have been observed to develop compulsive gambling in some individuals.

8. On average, slot machines take in more than $1 billion in wagers, some of which is paid back to the gamblers. The rest, called the “_________,” is what casinos make.’a. Hold.b. Vault.c. Cage.d. Bank.

9. Nevada was rated the most dangerous state in the nation recent years in a row.a. Six.b. Seven.c. Nine.d. Twelve.

10. Treatment programs that have proven successful include the following EXCEPT:a. Rational emotive therapy.b. Cognitive behavioral therapy.c. Removing the individual from family and friends and all

sources of gambling until the urge to gamble is gone.d. Medications including antidepressants (SSRIs), mood

stabilizers and anti-seizure drugs.

11. Reasons people give for gambling include all of the following EXCEPT:a. To indulge in masochistic tendencies.b. To be more social and overcome shyness.c. To alleviate boredom or loneliness.d. To solve money problems.

12. Warning signs of a relapse include all of the following EXCEPT:a. Minor depression.b. Lots of constructive planning.c. Progressive loss of daily structure.d. Visible gain in self-confidence.

13. Within two years of legalized gambling in South Dakota, gambling addiction had already become one of the leading causes of personal and business _______ filings.a. Foreclosure.b. Bankruptcy.c. Repossession.d. Separation.

14. In a 2010 poll conducted by the Saint Consulting Group, _____ percent of the Americans polled said they were against a casino being built in their community.a. 17.b. 37.c. 72.d. 77.

15. In 2010, ______ states sought to expand gambling to some degree, and Hawaii debated whether to introduce legalized gambling for the first time.a. 7.b. 17.c. 27.d. 37.

SWUS06GA14


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